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Status Report on DOC’s
Action Plan
by the
Nunez Independent Monitor

April 3, 2023

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THE NUNEZ MONITORING TEAM

Steve J. Martin
Monitor
Kelly Dedel, Ph.D.
Subject Matter Expert
Anna E. Friedberg
Deputy Monitor
Dennis O. Gonzalez
Associate Director
Patrick Hurley
Subject Matter Expert
Alycia M. Karlovich
Analyst
Emmitt Sparkman
Subject Matter Expert
Christina Bucci Vanderveer
Associate Deputy Monitor

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Introduction ................................................................................................................................... 1
Background ............................................................................................................................ 1
Current State of Affairs.......................................................................................................... 3
Role of the Monitor................................................................................................................ 6
Assessment of Progress ......................................................................................................... 7
Structure of the Report ........................................................................................................... 9
Progress Update on the Action Plan.......................................................................................... 11
Uniform Staffing Practices ..................................................................................................... 11
Background .......................................................................................................................... 11
Efforts to Ensure a Workforce of an Appropriate Size ........................................................ 13
Status of Efforts to Improve Availability of Staff ............................................................... 14
Staff Assignment in the Jails ............................................................................................... 17
Initiatives to Manage Staff on Sick Leave and Modified Duty ........................................... 23
Accountability for Abuse of Leave & Modified Duty......................................................... 30
Summary & Next Steps ....................................................................................................... 34
Security Practices & Indicators .............................................................................................. 36
Security and UOF Practices ................................................................................................. 37
Staff Supervision.................................................................................................................. 39
Security Initiatives ............................................................................................................... 44
Security Indicators ............................................................................................................... 47
Facility Specific Initiatives .................................................................................................. 52
Current State of Affairs & Moving Forward ....................................................................... 62
Deaths of Individuals in Custody ............................................................................................ 64
Intake ..................................................................................................................................... 73
Intake for People Newly Admitted to the Department ........................................................ 74
Intake for those Transferred Within and Between Facilities ............................................... 81
Quality Assurance of Department’s Tracking Efforts ......................................................... 84
Conclusion & Next Steps..................................................................................................... 87
Classification of Individuals in Custody ................................................................................. 89
Classification Process .......................................................................................................... 89
Blending of Housing for Security Risk Groups ................................................................... 92
Managing Incarcerated Individuals Following Serious Incidents of Violence ...................... 95
Staff Accountability ............................................................................................................... 100
Investigations ..................................................................................................................... 100
Discipline ........................................................................................................................... 102
Looking Ahead .................................................................................................................. 106
Overarching Initiatives Related to Reforms ......................................................................... 110
Recruitment Efforts............................................................................................................ 110
Department’s Engagement, Focus, and Collaboration Related to the Court’s Orders ...... 113
Training Initiatives ............................................................................................................. 115
City-Wide Support of Reform Efforts ............................................................................... 116
Reducing the Population & Addressing Increasing Lengths of Stay in Custody .............. 117
15th Monitoring Period Compliance Assessment for Select Provisions of the Consent
Judgment and First Remedial Order ...................................................................................... 122
Initiatives to Enhance Safe Custody Management, Improve Staff Supervision, and
Reduce Unnecessary Use of Force (Remedial Order § A) ......................................... 124
Use of Force Policy (Consent Judgment § IV) ........................................................... 144
Use of Force Reporting and Tracking (Consent Judgment § V) ................................ 146
Use of Force Investigations (Consent Judgment § VII).............................................. 155

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Risk Management (Consent Judgment § X) ............................................................... 172
Staff Discipline and Accountability
(Consent Judgment § VIII & Remedial Order § C) .................................................... 176
Screening & Assignment of Staff (Consent Judgment § XII) .................................... 210
Safety and Supervision of Inmates Under the Age of 19 (Consent Judgment § XV) 217
Conclusion ................................................................................................................................. 220
Immediate Next Steps & Future Reporting ........................................................................ 222
Appendix A: Additional Data ....................................................................................................... i
Installation of Cell Doors ....................................................................................................... ii
Facility Searches & Contraband Recovery ........................................................................... iii
Data Regarding Unmanned Posts & Triple Tours ................................................................ iv
Use of Force Involving Unmanned Posts ............................................................................. vi
Sick Leave, Medically Monitored/Restricted, and AWOL Data ......................................... vii
Staff Suspensions ................................................................................................................... x
OATH Pre-Trial Conferences ............................................................................................... xi
Individuals Who Died While in the Custody of the New York City DOC ......................... xii
Appendix B: Definitions ........................................................................................................... xiv
Appendix C: Flowchart of Promotions Process ..................................................................... xix

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INTRODUCTION
This report is the fourth filed by the Monitoring Team since the Action Plan was ordered
by the Court on June 14, 2022 (dkt. 465). Throughout this time, the Monitoring Team has been
actively monitoring and engaged with the Department, has consulted with the Parties, and has
met with the Court. The purpose of this report is to provide a neutral and independent assessment
of the Department’s efforts to achieve compliance with the Action Plan’s requirements, and other
relevant orders, and to inform the Court and Parties about the current state of affairs.
As in all complex institutional reform cases, time is of the essence when issues of
constitutional dimension are at play. That said, changes of the magnitude necessary to transform
the jails simply cannot be accomplished quickly or by large leaps and bounds. The Monitoring
Team’s experience suggests that progress toward safe facilities becomes evident via small
improvements that accumulate over a long period of time. The pace of reform, to date, has been
unquestionably slow and must be accelerated. Nonetheless, there have been improvements in
addressing core foundational issues and in remediating the dangerous conditions in the jails—but
the current state of affairs remains deeply troubling. Recent signs indicate the Department is
beginning to reverse the spiral of chaos and disorder of the last few years and that the reforms are
gaining momentum.
Background
The Consent Judgment put into effect in 2015 did not anticipate the depth of dysfunction
in staffing and basic security operations in the jails and thus, the reforms required by that
document presupposed a foundational layer that did not, in fact, exist. The perfect storm
presented by the COVID pandemic, the ensuing staffing crisis, and a revolving door of
leadership (three different Commissioners in nine months, May 2021 to January 2022)
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threatened to collapse a system that was already reeling from a poor foundation weakened by
decades of neglect and both internal and external mismanagement. Thus, the Department has
been trapped in a state of persistent dysfunction, where even the first step to improve practice has
been undercut by the absence of elementary skills and basic correctional practices and systems.
The creation of the Action Plan in June 2022 provided a roadmap for building the necessary
foundations of proper staff management, security practices, safe management of people in
custody and discipline for staff misconduct—upon which future improvements to the practices
outlined in the Consent Judgment could be built upon. The Monitoring Team has often warned
that addressing these complicated problems will take significant time, and certainly longer than
the inherent danger of the jails should afford, because the solutions are every bit as complex as
the problems.
The Monitoring Team has provided a significant volume of reporting on the conditions of
the jails. What must not be lost in this maze of documentation is the fact that real harm to both
people in custody and staff continues to occur at unacceptable levels. The unacceptable rates of
use of force, fights, assaults on staff and stabbing and slashings cause both physical and
emotional harm. The sheer number of incidents cannot begin to capture the real abject harm that
occurs in this setting. These incidents can be described and reported in words, but it is almost
impossible to understand how the current “predatory environment” is experienced by the typical
person in custody or staff member. The harm can be witnessed directly in the images from inside
the jails— images of chaos, disorder, and sometimes serious injuries—which still belie the real
fear felt by the participants, witnesses, and bystanders in real time.
Managing this Department requires a strong command of and ability to articulate a wide
array of interconnected initiatives with an ever-demanding group of stakeholders, each with

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often contradictory agendas and priorities. In the midst of such a challenging setting, the focus
must be to advance those management choices that foster sound correctional practices among the
people closest to the day-to-day operation of the jails, practices that have not been embraced
fully by either facility leadership or line staff. Consequently, the success or failure of the reform
effort depends heavily on recruiting competent individuals to manage and operate the jails. In
other words, ensuring the acumen of those who work in the jails each and every day is the most
daunting, and yet the most critical, task that lies ahead.
Current State of Affairs
The Department has taken some important initial steps in building each area of this
desperately needed foundation, as the rest of this report details. The Department’s headquarters
and the jails’ conditions of confinement may be best described as in a state of flux, as both begin
to gradually transition away from deep dysfunction towards the beginnings of improved
management. To be sure, the overall number of use of force incidents remains too high as do the
instances of unnecessary and excessive force. Further, assaults on staff and violence among
people in custody also remain at unacceptable levels and the number of recent in-custody deaths
is alarming.
In each of the four main areas of the Action Plan (Staffing, Security, Discipline, and
Management of Individuals in Custody), the Department has developed insight into the nuances
of the problems and has crafted a logical, orderly plan for how to address them. In many cases,
the initial steps have been taken and the impact on intermediate outcomes appears to be
promising. This is not to suggest that the problems are anywhere near close to being resolved,
but rather that the Department has made some important changes to its foundational practices
that are well-grounded in sound correctional practice and that hold promise for catalyzing the
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necessary reforms. If successful, this transition will begin to stabilize what has been for decades
an unsafe setting for both detainees and staff.
The four new Deputy Commissioners for (1) Classification, Custody Management and
Facility Operations; (2) Administration; (3) Security; and (4) Training and Development and the
two new Associate Commissioners of Operations are making administrative gains that have
catalyzed some positive organizational momentum. There are:
•

Identifiable improvements in staff deployment and increasing numbers of staff who are
available to work with the incarcerated population.

•

Definitive steps have been taken to improve security practices, most evident at RNDC
and GRVC.

•

Initiatives to improve the Department’s practices related to preventing self-harm and
evaluating the circumstances surrounding deaths in custody so that future tragedies may
be avoided.

•

Intake processing has become more orderly and efficient.

•

Classification processes are being refined to properly address both risk and gang
affiliation, and efforts are underway to implement an appropriate housing strategy for
those individuals who engage in serious acts of violence.

•

The Trials and OATH Divisions have made positive gains in improving the disciplinary
process and imposing discipline in response to staff misconduct.

•

In April 2023, five Assistant Commissioners of Operations are slated to begin serving as
the Wardens in the facilities.
In the Monitoring Team’s experience, these small changes often allow bigger, more

pronounced changes to become possible. The Monitoring Team is particularly focused on
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necessary changes in the day-to-day management and operation of the facilities (including
response teams) and on shoring up elements of the investigation and disciplinary processing that
have recently lost ground or otherwise become more salient.
While clear progress is being made at the executive level of the agency, the tangible
difference made by those with experience external to this Department underscores the
importance of infusing the facilities themselves with this same level of competence and
commitment to better practice. Ensuring that the four levels of managers/supervisors (Warden,
Deputy Warden (“DW”), Assistant Deputy Warden “(ADW”), and Captain) in each jail have the
skill and willingness to guide better practice among line staff is the next major challenge that lies
ahead, and arguably the one that will make the biggest impact on the conditions in the jails. For
example, the Monitoring Team recently identified some questionable promotions of ADWs who
did not appear to have the requisite level of competence in this critical echelon of uniformed
security. These concerning promotions are partly a reflection of the fact that staff competency in
basic supervision is limited. The rank of ADW is ripe for intensive mentoring to help them to
develop the skills they will need, and the infusion of correctional expertise in the facilities,
especially, the new Assistant Commissioners of Operations (who will serve as the Wardens of
the facility) are expected to support this improvement. Further, the Monitoring Team’s survey of
personnel permitted to occupy positions on the Emergency Services Unit (“ESU”), the
Department’s elite tactical squad, gives rise to questions about the leadership of this division and
the fidelity to which individuals are selected to serve on this team that should be models of deescalation rather than continually exacerbates problems.
Finally, the most disturbing pattern that emerged during this reporting period is the
decline in performance of the Investigations Division (“ID”), which is the sine qua non of

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accountability for adherence to the Use of Force Directive. Much progress had been made with
respect to the operations of the ID during the previous seven years. Unfortunately, the new
leadership of ID was unable to sustain this momentum, which resulted in a measurable
diminution of ID’s performance such that misconduct is not currently subject to the investigative
necessary to identify all staff who engage in unnecessary and excessive force. A very recent
change in ID’s leadership (at the end of March 2023) creates an opportunity for the Department
to prevent further deterioration and to regain the ground that has been lost, assuming the
selection of an appropriately skilled individual who is committed to fulfilling the requirements of
the Consent Judgment.
Moving forward, the Department’s continued progress will operate on many planes. For
new practices recently implemented, the Department must focus on the fidelity of the
implementation, on the quality of practice, and on the choices that staff make moment-tomoment. At the same time, Department leaders must prepare to layer on the next sets of
procedural and practice enhancements and must begin to assess whether those appear to be
achieving the intended intermediate outcomes. Obviously, a major task will be appropriately
sequencing and prioritizing so that the many layers of reform occur in a coherent and organized
manner. This is no small undertaking, and the Monitoring Team stands at the ready to provide
any assistance necessary to facilitate the positive changes that are beginning to occur.
Role of the Monitor
The Monitoring Team has several key responsibilities. Chief among them is providing
transparency about the Department’s progress towards achieving compliance with the various
court orders. This has been particularly crucial in dealing with such a dysfunctional system. In its
role, the Monitoring Team provides a description of what is currently occurring, obstacles to

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reform, and how the Department’s practices comport with sound correctional practice. As long
noted, simply requiring the Department to do something and reporting on whether it has been
done is insufficient to actually catalyze the magnitude of change that is needed in this system.
This is why the Monitoring Team has endeavored to provide the Court and the Parties to the
Nunez litigation with the information necessary to understand why the current state of affairs is
what it is, how it compares to sound correctional practice, and, when appropriate, to advise how
practice and procedures can be improved. As part of this work, the Monitoring Team has
provided extensive recommendations and technical assistance on how to build many of the
foundational systems discussed in this report that are necessary to support the reform. However,
to be certain, the Monitoring Team does not act in the Department’s place, nor can it insist that
the Department proceed in a certain way. Ultimately, it is the City and the Department that must
guide, direct and implement the requirements of the Court’s orders. The ultimate goal of any
type of institutional reform is for the system to develop an internal capacity to identify and solve
its own problems, without the need for external oversight to untangle the problems or instigate
the motivation to address them.
Assessment of Progress
The Monitoring Team’s assessment of progress requires evaluation of multiple measures
in each key area of the Consent Judgment, Remedial Orders, and Action Plan (e.g., staffing,
safety and security, staff discipline) because no one metric adequately represents the multifaceted nature of these requirements. While quantitative data is a necessary component of any
analysis, relegating a nuanced, complex, qualitative assessment of progress towards achieving
compliance with these requirements into a single, one-dimensional, quantitative metric is not
practical or advisable. Data—whether qualitative or quantitative—cannot be interpreted in a

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vacuum to determine whether progress has been made or compliance has been achieved. For
example, meeting the requirements of the Staffing section of the Action Plan relies on a series of
closely related and interdependent requirements (e.g., unpacking the source of the dysfunction
regarding abuse of leave, modernizing systems for scheduling staff, and teaching facility leaders
how to properly deploy staff to meet the Department’s core responsibilities) working in tandem
to ultimately increase the number of staff who are available to work directly with incarcerated
individuals. As such, there is no single number that could determine whether the Staffing section
of the Action Plan has been properly implemented. Analogous situations appear throughout this
report, whether focused on discussions about improving safety in the facilities or making the
process for imposing staff discipline timelier and more effective. The Monitoring Team therefore
uses a combination of quantitative data, qualitative data, contextual factors, and the standard of
practice to assess progress with each of the Action Plan’s requirements.
Further, two cautions are needed about the use of quantitative metrics. First, the use of
numerical data suggests that there is a line in the sand that specifies a certain point at which the
Department passes or fails. There are no national standards regarding a “safe” use of force rate, a
reasonable number of “unnecessary or excessive uses of force” nor an “appropriate” rate at
which staff are held accountable. 1 The Monitoring Team’s multi-faceted strategy for assessing
compliance requires an assessment of all inter-related issues, because each of the main Action
Plan requirements is more than simply the sum of its parts. For this type of analysis, the
experience and subject matter expertise of the Monitoring Team is critical, to not only

Notably, this is why the Consent Judgment, the underlying Nunez litigation, CRIPA investigation the
Remedial Orders, nor the Action Plan include specific metrics the Department must meet with respect to
operational and security standards that must be achieved.

1

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contextualize the information, but also to compare the Department’s performance to their
decades-long, deep experience with the operation of other jail systems.
Second, there are infinite options for quantifying the many aspects of the Departments’
approach and results. Just because something can be quantified, does not mean it is useful for
understanding or assessing progress. The task is to identify those metrics that actually provide
insight into the Department’s processes and outcomes and are useful to the task of problem
solving. If not anchored to a commitment to advance and improve the way the Department is
doing something or to the results it is trying to achieve, the development of metrics merely
becomes a burdensome and bureaucratic task that distracts from the qualitative assessments
needed to understand and more importantly, improve, the processes and outcomes that underpin
the requirements of the Consent Judgment and Remedial Order. Poorly conceptualized metrics
create an unnecessary focus on “counting” instead of solving the actual problems at hand. In
short, while there are certain ad hoc requirements that are amenable to the development of
metrics, overall, the Monitoring Team strongly discourages a strategy that relies on a single
metric against which progress is measured. As a cautionary observation, it should be noted that
solutions which are overly encumbered by legalese, or are hyper-technical or arbitrary, often
imposed under the guise of problem-solving, can sometimes have the unintended effect of
undermining the reform effort rather than strengthening it.
Structure of the Report
This report has three sections. The first section focuses on the work related to the Action
Plan and the current state of affairs, including: Uniform Staffing Practices, Security Practices &
Indicators, Deaths of Individuals in Custody, Intake, Classification of Individuals in Custody,
Managing Incarcerated Individuals Following Serious Incidents of Violence, Staff

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Accountability, and Overarching Initiatives Related to Reform. When applicable, the Monitoring
Team offers concrete recommendations for the Department’s focus in the near term. The second
part of the report is the 15th Monitoring Period Compliance Assessment for Select Provisions of
the Consent Judgment and First Remedial Order (“Compliance Assessment section”). 2 The final
section of the report is the first Appendix A: Additional Data containing additional information
and data not otherwise provided in body of this report.

§ G., ¶ 5 of the Action Plan requires the Monitoring Team to assess compliance with the following
provisions for the period covering January 1 – June 30, 2022: Consent Judgment § IV., ¶ 1 (Use of Force
Policy); § V., ¶¶ 2 & 22 (Use of Force Reporting and Tracking); § VII., ¶¶ 1 & 9(a) (Use of Force
Investigations); § VIII., ¶¶ 1, 3(c) and 4 (Staff Discipline and Accountability); § X., ¶ 1 (Risk
Management); § XII., ¶¶ 1, 2 and 3 (Screening and Assignment of Staff); § XV., ¶¶ 1, 12 and 17 (Safety
and Supervision of Inmates Under the Age of 19); as well as First Remedial Order § A., ¶¶ 1 to 4 and 6
(Initiatives to Enhance Safe Custody Management, Improve Staff Supervision and Reduce Unnecessary
Use of Force) and § C., ¶¶ 1, 2, 4 and 5 (Timely, Appropriate and Meaningful Staff Accountability).

2

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PROGRESS UPDATE ON THE ACTION PLAN
UNIFORM STAFFING PRACTICES
The Department has made appreciable progress in managing its uniform staff and
untangling the dysfunctional staffing practices that have been entrenched for decades. To be
certain, significant work remains for the Department to properly manage its staff and to instill
new practices consistently over time. Given the complexity of the task and the sheer number of
staff that must be managed, this process will take considerable time. That said, the Department’s
efforts to date have already begun to improve practice and certainly suggest the Department is in
a position to reverse the poor practices of the past and to create a sustainable process going
forward should it maintain the same level of focus and dedication that has been expended since
the Action Plan was put in place.
Background
The Monitoring Team has long been concerned about the way staff are assigned within
the jails. Not only are practices inefficient, but also misaligned with the values that undergird the
reform effort, such as de-escalation and reliable service provision on the housing units. These
concerns and findings long pre-date the staffing crisis in 2021 in which a different, but
corresponding, staff management issue was exposed with respect to the lack of controls to
manage staff who may not be available to work. The Department’s staffing model was
dysfunctional, antiquated, deeply entrenched, and mainly paper-based with no overarching
staffing plan, built-in controls, or oversight. The convergence of the Department’s poor staff
assignment practices, and the lack of adequate control and enforcement of leave and modified
duty procedures left the facilities without sufficient staff to provide adequate safety and access to

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services. It is for these reasons that the Action Plan (§ C., ¶ 1) required the appointment of a
Staffing Manager with external expertise in sound correctional management, who would be
charged with overhauling the Department’s staffing tools and protocols in order to maximize the
assignment of staff within the jails pursuant to Action Plan § C., ¶ 3. Simultaneously, the Action
Plan (§ A., ¶ 2(d) to (g)) also requires the Department to implement adequate controls to
eliminate the abuse of sick leave and other problems that permitted such high numbers of staff to
be unavailable to work in the jails.
The Department has long had, and continues to have, a large workforce. As the various
staffing problems have slowly become untangled, it is clear that properly assigning staff would
provide sufficient coverage to enhance safety in the jails, even with a reasonable number of staff
on sick leave/modified duty and even though the size of the Department’s workforce has
decreased over time. Since the Action Plan went into effect, the Department has developed some
new resources and tools that should facilitate the necessary improvements to its staffing
practices. These include the appointment of a Staffing Manager with significant expertise in
sound correctional practices for managing Staff, the use of automated workforce
management/scheduling software (i.e., InTime) for roster management, sorely needed updates to
antiquated staffing conventions, and a new focus by the Department (including new protocols
and enforcement strategies) on properly managing staff on leave and modified duty. These
advances are described in detail below, and are already having an impact as staff appear to be
assigned to posts within facilities more appropriately with a corresponding reduction in the
number of unstaffed posts, and a significant decrease in the number of staff who are unavailable
to work. These are important improvements to a system that, until very recently, appeared to be
on the brink of a staffing collapse.

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Efforts to Ensure a Workforce of an Appropriate Size
The current size of the workforce (approximately 6,600 uniform staff) is about 35%
smaller than it was at its peak five years ago. Prior to 2019, the Department had a larger
workforce (10,000+ uniform staff) than any jurisdiction with which the Monitoring Team is
familiar. This provided a functional margin that allowed the Department to continue to staff the
jails even with large numbers of staff on sick leave or modified duty for extended periods of
time, and even with a multitude of scheduling inefficiencies and poor management practices.
While the smaller workforce of recent times does not provide the extremely generous margin that
allowed the Department to remain functional despite deep problems with its staff management
practices, this smaller workforce it is still sufficient to provide adequate supervision of people in
custody if efforts to efficiently schedule and properly deploy staff are implemented across all
facilities, and if abuses of staff leave and modified duty are effectively curtailed.
The Staffing Manager’s work to maximize staff deployment efficiencies and the
Department’s efforts to ensure that only a reasonable number of staff are on leave at a given time
(versus the excessive number of staff on leave currently) will provide a well-grounded approach
to determining staffing needs. In other words, this foundation will create an ability to properly
ascertain the number of staff needed to manage the jails. To date, the Department has been
unable to do so with any sort of data-driven rationale.
Of course, the Department cannot withstand a continuous reduction in the size of its
workforce via attrition without backfilling at least some of the vacant positions with new recruits.
The Department must ensure that hiring efforts mitigate rising attrition rates, but this is not to say
that the Department’s staffing level needs to return to its apex of over 10,500 staff. Therefore,
recruiting new staff is also necessary. To that end, the Department has a recruitment target of 500

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officers for 2023. 3 The ongoing staffing crisis, the conditions in the jails, and overall tenor of the
public discourse make it particularly difficult to both retain and attract staff. This is compounded
by the fact that all correctional systems with which the Monitoring Team is familiar are
struggling to attract new staff and to retain existing staff during the post-COVID era, a trend that
is evident within other New York City agencies as well.
Status of Efforts to Improve Availability of Staff
The improvements in the Department’s staffing practices are most evident in the
decreases in the number of unstaffed posts, the decrease in staff working triple shifts, as well as
the increase in the number and proportion of staff available to work with the incarcerated
population, as discussed in more detail below.
Important decreases in the number of unstaffed posts 4 and staff working triple shifts have
occurred. As shown in the table below, the number of unstaffed posts decreased 99%, from an
average of 68.27 per day (July to December, 2021) to an average of just 0.65 per day (July to
December, 2022). In addition, the number of staff required to work triple shifts decreased 78%,
from an average of 20.65 staff per day (July to December, 2021) to 4.48 staff per day (July to
December, 2022).

Approximately 610 officers were hired between 2019 and 2022 (380 new officers were hired and
onboarded in 2019, none were hired in 2020 or 2021, and 230 new officers were hired and onboarded in
2022). Between 2015 and 2018, the Department engaged in a significant recruitment effort when over
5,600 officers were hired and onboarded during that four-year period.

3

4

Note, this does not include a post in which a staff member, after being assigned, may abandon that post.

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Unstaffed Posts and Triple Shifts, July 2021 to December 2022
Unstaffed Posts

Triple Shifts

Total #
Unstaffed
Posts

Daily
Average #
Unstaffed
Posts

Total # Triple
Shifts

Daily Average #
Triple Shifts

July to December, 2021

8,192*

68.27

3,717

20.65

January to June, 2022

5,490

30.50

1,950

10.83

118

0.65

808

4.48

Monitoring Period

July to December, 2022

* Note: The Department did not begin tracking unstaffed posts until September 2021, so data for this period
does not include July or August, 2021.

It must be emphasized that any unstaffed post and any need for staff to work multiple
shifts are antithetical to a healthy and safe correctional operation.
Problems related to sick leave and modified duty have also shown encouraging
improvements. As shown in the table below, the number of staff in each category has
substantially decreased. For example, the average number of staff out sick decreased 66%
between January 2022 (when the new Commissioner was appointed) and February 2023. The
number of staff on MMR 5 decreased 38% (from 685 to 422) and the number of staff who were
AWOL decreased 79% (from 42 to 9) during this same time period. Decreases in the proportion
of staff on these three statuses are of a similar magnitude (proportion out sick decreased 66%,
MMR decreased 33%, AWOL is too small for meaningful calculation).

Medically Modified/Restricted Duty Status in which staff may not have direct contact with incarcerated
individuals.
5

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Sick Leave, Medically Modified Duty and AWOL, January 2019 to February 2023
Month

Total Headcount

Avg. # Sick (%)

Avg. # MMR (%)

Avg. # AWOL (%)

January 2019
Pre-COVID-19

10,577

621 (6%)

459 (4%)

Not Available

April 2020
Apex of COVID-19

9,481

3,059 (32%)

278 (3%)

Not Available

September 2021
Apex of Staffing Crisis

8,081

1,703 (21%)

744 (9%)

77 (1%)

January 2022
New Commissioner

7,668

2,005 (26%)

685 (9%)

42 (1%)

June 2022
Action Plan Effective Date

7,150

951 (13%)

624 (9%)

16 (<1%)

December 2022
End of 15th Monitoring
Period

6,777

754 (11%)

452 (7%)

7 (<1%)

February 2023
Most Recent Data

6,632

680 (10%)

421 (6%)

9 (<1%)

The Department’s data also reflect a significant decrease in the number of staff on
indefinite sick leave (i.e., staff on sick leave for 30 or more days). The number of staff on
indefinite sick leave decreased 54% between February 2022 (n=978) and December 2022
(n=450). Combined, these decreases translate to an increasing proportion of staff who are able to
work directly with the incarcerated population, which is particularly essential given that the
overall size of the workforce decreased 14% during this same time (from 7,668 to 6,625).
While the situation has recently improved, the proportion of staff who are unavailable to
work is still high. More specifically, at least 10% of the workforce is not available to work with
the incarcerated population on any given day, which is higher than the proportion of staff out
sick or on MMR status prior to the COVID-19 pandemic. 6

The number of staff on sick leave and MMR cannot be combined because staff on MMR may also be
out sick.

6

16

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While the actual number of staff on sick leave and MMR duty are very similar to the
number of staff in these categories prior to the onset of the COVID-19 pandemic, given the
significant rate of attrition of staff at DOC since the pandemic, the proportion of the workforce
represented by those out sick or on MMR is slightly higher. Higher rates of absenteeism postCOVID have been seen in correctional systems throughout the country as well as in other large
uniform agencies in the City (e.g., the Fire Department and the Department of Sanitation). 7 It is
therefore difficult to ascertain what reasonable absenteeism rates may be under these
circumstances. Further reductions are necessary, and the Department is now in a position to
continue working toward that goal.
Staff Assignment in the Jails
The Department has lacked an appropriate framework and basic tools to properly
administer staff assignments, particularly because of poor scheduling and deployment practices.
As an initial matter, all staff scheduling was paper-based, with a small subset of information that
was manually inputted into a computer for tracking purposes. 8 Problems included indecipherable
facility schedules to identify who was expected and who actually reported to work on a given
day, and a lack of fair and consistent mechanisms for assigning staff to work overtime. In
addition, the Department’s staff deployment practices did not make the best use of its workforce
because uniformed staff were routinely utilized for job duties that did not prioritize work with
the incarcerated population, priority posts were not identified for mandatory coverage, the use of

The Comptroller’s most recent Agency Watch List report notes that the proportion of staff out sick for
the Fire Department and Department of Sanitation are both higher than it was prior to the COVID
pandemic. See Lander, B. (2022). Agency Watch List: Department of Correction, FY2023. New York
City Bureau of Budget: New York, NY, pg. 10. Available at: https://comptroller.nyc.gov/reports/agencywatch-list/fy-2023/department-of-correction-fy-2023/.
7

8

This is the predominant reason that historical data regarding staff assignment are not readily available.

17

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awarded posts limited flexibility in deploying staff to places where they were most needed, and
work schedules (e.g., days on/off, split shifts) were often illogical. Further, some uniform staff
were temporarily deployed to various locations outside of the jails, and others performed tasks
that could be done by civilians. In addition, both scheduling and deployment practices were often
unfairly administered and poorly monitored by facility supervisors and leadership.
The well-qualified Deputy Commissioner for Administration (“Staffing Manager”) 9 who
began his tenure in September 2022 continues to untangle the Department’s complex staffing
problems in order to develop and implement multi-faceted solutions. The Staffing Manager
oversees the Office of Administration which includes the roster management unit, called the
Schedule Management and Redeployment Team (“SMART”). 10 SMART includes one
supervisor, eight officers, and a civilian administrative assistant. The officers were previously
assigned to scheduling duties in the jails but were reassigned to SMART to ensure consistency
and accountability. Offers have been extended to qualified candidates for various civilian
positions but to date all offers have been declined, reportedly because SMART candidates are
unwilling to commute to Rikers Island (the location of the unit is essential so that SMART staff
remain in close contact with the jails). The Staffing Manager reported that filling the vacant
manager position for the SMART unit is a key priority.
The Staffing Manager has taken meaningful action to improve how staff are scheduled
and deployed within the jails. Not only has the Staffing Manager brought the Department current
with scheduling innovations (e.g., rolling out software for roster management) and aligned core

9

As required by Action Plan § C, ¶ 1.

10

As required by § C, ¶ 2.

18

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pillars of roster management with best practice (e.g., maximizing hours available via work
schedules, focusing on increasing the size of the pool that is capable of fulfilling a variety of job
duties), but he is also focused on identifying and rectifying the many places and ways in which
uniformed staff resources were previously wasted. The planning work that began in summer
2022 has recently culminated in implementing these initiatives. Beginning in January 2023, a
combination of initiatives were rolled out Department-wide, while others will be rolled out
sequentially in the facilities, as outlined in more detail below.
•

Modern Tools for Staff Schedules & Tracking Attendance
o Implementing InTime Scheduling Software: The Department has procured and
customized a cloud-based, single source tracking system, InTime. 11 In recent

months, SMART and facility staff were trained to use the system, and InTime
replaced the legacy paper-based system at RNDC in January 2023, GRVC in
February 2023, and EMTC and VCBC in March 2023. A rolling schedule of
implementation for the remaining facilities has been established to meet the June
1, 2023 timeline in the Action Plan. 12
o Improving Staff Scheduling: Prior to implementing the InTime system at a given
facility, several analyses are conducted. These actions address multiple

requirements of the Action Plan. A facility-specific staffing analysis is conducted
to identify the number of people (and their assigned shift) on the facility’s staffing
roster and a post analysis is conducted to examine the number and job
responsibilities of each post in the facility. Further, a list of uniformed staff
assigned to each command is created, along with a post assignment classification
system for every command. 13

11

As required by Action Plan § A, ¶ 5.

12

As required by § C, ¶ 5 and § C, ¶ 3(i).

13

As required by § C, ¶¶ 3(i), 3(viii) and ¶ 5.

19

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o Prioritizing Posts: In each facility, posts in the housing units, central control,

intake and program-related are prioritized to ensure these take precedence on all
daily rosters. The job responsibilities of all facility posts are also analyzed to
maximize efficient deployment. Procedures are put in place to ensure that priority
posts are filled before non-priority posts. 14


SMART staff provide real-time assistance to the facilities to ensure all
priority posts have a staff assigned per the schedule and that schedules are
accurate (including properly documenting reasons staff may be out such as
training, leave, FMLA, etc.). SMART staff also assess the accuracy of the
daily line up (i.e., daily roster) by verifying post manning within each
facility using the staff attendance scanning system described below.

o Attendance Scanning System: The Department has begun to utilize a staff
scanning system wherein each staff scans their ID card upon facility entry/exit
and arrival/departure at their assigned post to ensure timekeeping integrity. This
was rolled out at RNDC in September 2022, EMTC in December 2022, and
GRVC in January 2023. The Department plans to expand its use to the remaining
facilities by June 2023. 15
o Next Steps: Once the efficiencies and mechanics of the new scheduling software
have become more routine, SMART will work toward ensuring that other
requirements of the Action Plan are consistently implemented, such as ensuring
that more experienced staff are tapped to work in the housing areas. 16 All of this
work will also support the efforts underway to develop an accurate relief factor
for each facility. 17
•

Reconstituting Wasteful Practices & Increasing Flexibility in Staff Assignments
o Maximizing Staff Schedules: Several changes to staff schedules have been
imposed to maximize staff deployment. First, given the increases in staff

14

As required by Action Plan § C, ¶ 3(i).

15

As required by § A, ¶ 2(c).

16

As required by Action Plan § C, ¶ 3(i) and § C, ¶ 3(iv).

17

As required by Action Plan § C, ¶ 3(ix).

20

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availability discussed above, as of early 2023, all facilities now operate using
three 8-hour shifts rather than two 12-hour shifts. 18 Further, the majority of posts
in the facilities now operate according to these same three shifts, in contrast to the
dizzying array of split shifts that characterized previous conventions. In addition,
the Department is working to convert more staff to a 5x2 schedule (5 days on, 2
days off) from a 4x2 schedule, which increases the proportion of the workforce
who is at work on any given day from one-half to two-thirds and thus provides
greater flexibility for coverage. 19 Since fall 2022, the number of staff on 4x2
schedules has decreased by 15% (4,132 staff

20

compared to 4,863 staff) and so

62% of the workforce is now on the 4x2 schedule compared to 70%. Finally, the
number of “squads” (i.e., groups with the same days off) was also reduced from
six to three. 21
o Staffing Flexibility: The practice of awarding posts has been suspended (meaning that
no additional posts will be awarded) in fall 2022. 22 In March 2023, the number of

staff on awarded posts was essentially the same as September 2022 (1,663 23 versus
1,661, respectively). 24 The Department reports that they have recently initiated a
review of each individual staff on awarded posts to determine whether those posts are
still appropriate. Another strategy to provide greater flexibility in staff scheduling is

Beginning in 2021, at the apex of the staffing crisis, the Department switched to a 12-hour work shift
because this convention requires few staff.

18

Many systems utilize a 5x2 schedule where staff work five consecutive 8.5-hour workdays, followed by
2 consecutive days off. Staff on 4x2 schedules work four consecutive 8.5-hour workdays, followed by 2
consecutive days off. By way of illustration, not accounting for staff on leave, 300 staff working 4x2
schedules are able to fill 2,800 posts over the course of 2 weeks, but 300 staff working 5x2 schedules are
able to fill 3,000 posts over 2 weeks. This difference is solely due to the differing work schedules and
assigned days off.
19

20

As of March 2023, 3,801 Officers, 282 Captains, and 49 ADWs are on 4x2 schedule.

21

As required by Action Plan § C, ¶ 3(vi).

22

As required by Action Plan § C, ¶ 3(v).

23

In total, 11 ADWs, 220 Captains and 1,432 Officers have awarded posts as of March 2023.

The Department reports that 1,661 staff had awarded posts in September 2022 (this is a slightly higher
figure than what was reported in the Monitor’s October 28, 2022 Report, because, after the report was
filed, the Department identified some errors with the data).
24

21

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the conversion of a variety of positions currently filled by uniformed staff to civilian
positions.25 As an initial matter, the Department’s staffing assessment identified
certain administrative posts (that have historically been filled by uniform staff) to be
altogether superfluous. In other words, not every administrative post currently held by
a uniform staff member needs to be converted to a civilian post—the post can simply
be eliminated. For example, the consolidation of roster management duties in the
SMART unit reduced the need for staff in each facility to manage schedules. Another
example is that officers assigned to ADWs as an assistant are in the process of being
reassigned, and the assistant positions were determined to be superfluous. The effort
to identify posts for potential conversion is continuing. Further, the Department
reports that the Department’s Chief of Staff, as well as representatives from the HR
and Administrative Divisions, are meeting with the leadership of each Facility to
identify posts that can be filled by civilians. Finally, the Department reports that
HMD will utilize civilian staff to conduct the work of the HMD sick desk and is
working with HR to advertise for these positions.
o Temporary Duty: DOC has reduced its reliance on Captains utilizing the Temporary
Duty status (“TDY”) and at least 20 Captains previously on TDY status have been
returned to posts in the jails. 26 About 30 Captains remain on long-term TDY status,
which is about 5% of all Captains in the Department. TDY status is used sparingly
and the circumstances in which the Department has reported using it appear
appropriate given certain budgetary factors and, in some cases, where specific
expertise is needed for a position. The Monitoring Team has evaluated the post
assignments of Captains who remain on long term TDY status, and the post
assignments appear reasonable.
•

Increased Supervision in the Facilities
o Deputy Warden Schedules: At the beginning of 2023, the Deputy Wardens’ schedules
were reorganized using staggered start times to provide better coverage throughout
the day (Deputy Wardens previously all worked on the same tour). Each Deputy

25

As required by Action Plan § C, ¶ 3(vii).

26

As required by Action Plan § A, ¶ 3(a)

22

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Warden is now also required to work one weekend day each week. This approach to
scheduling is consistent with sound correctional practice in which a Deputy Warden
is available for a large portion of each day.
o Reassignment of ADWs and Captains: A Department-wide evaluation has begun to

assess ADW 27 and Captain 28 assignments across facilities, to broaden the presence of

supervisors throughout evenings and weekends, and to ensure that Captains have an
appropriate span of control (meaning, how many staff they supervise). This
evaluation is expected to be completed and implemented by mid- to late April 2023.

The positive impact of the Staffing Manager, his team, and other leaders in the agency
who have supported this effort (especially the Deputy Commissioner of IT and her team) is
clearly evident. Facility leadership reported close collaboration with their SMART liaisons, and
appreciated the simplicity, clarity, efficiency, and organization that InTime delivers. They also
recognized the important connection between effective staffing conventions and facility safety
and thus appear to be enthusiastic partners in this work. While several key steps remain,
important progress has been made to date and the subsequent tasks are being appropriately
managed and properly sequenced. The portion of the Department’s foundation that is comprised
of staffing practices is unquestionably taking shape, and will bring additional elements of the
Action Plan, Remedial Orders, and Consent Judgment within reach.
Initiatives to Manage Staff on Sick Leave and Modified Duty
The Department has made significant strides in appropriately managing staff on leave and
modified duty since the staffing crisis revealed that the Department has never had durable
protocols for this purpose. Historically, as discussed above, the large size of the workforce

27

As required by Action Plan § C, ¶ 3(iii)

28

As required by Action Plan § C, ¶ 3(ii)

23

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essentially obscured how poorly the Department managed these important benefits and statuses.
However, in recent years, the size and scope of the problem increased exponentially when the
decrease in the size of the workforce combined with the onslaught of the COVID-19 pandemic.
As shown in the table in the introduction to this section, in 2020 and 2021, the Department was
crippled by the large number of staff out sick (20-30% of the workforce) and the large number of
staff with a restricted medical status (3-9% of the workforce). 29 Thus, what began as a long
history of mismanagement escalated to a crisis, one that threatened to fully collapse the system
given the corresponding issues with staff assignment discussed above, hence the Action Plan’s
emphasis on this issue.
Sick leave benefits are provided to staff as an essential component of staff wellness—
particularly in an agency where job responsibilities are inherently dangerous and stressful—but
the Department’s practices were ripe for abuse given how poorly the benefit had been managed.
The Department’s generous sick leave benefits have been characterized as “unlimited sick
leave,” but as outlined in the Monitor’s October 28, 2022 Report, staff sick leave benefits are
not actually unlimited, although mismanagement and a lack of policy enforcement resulted in
staff obtaining unlimited sick leave benefits. The staff leave benefit is not, itself, the cause of the
staffing crisis (see pg. 44-45 of the Monitor’s October 28, 2022 Report). Proper management and
enforcement of existing constraints on these benefits as imposed by New York Civil Service
Laws §§ 71, 72, and 73 and Department policy (with appropriate revisions) would put
appropriate constraints on these benefits. This is why the Department needed to develop new
practices that are capable of identifying those who need and use the benefit for a legitimate

Sick leave and restricted medical statuses are utilized for both work-related and non-work-related
illnesses and injuries.
29

24

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reason and those whose use of the benefit is unnecessary or excessive. As discussed below,
current efforts to strengthen protocols have put the Department on the proper trajectory for
properly discriminating between legitimate uses and potential abuses, but more work remains.
The Department, under the leadership of the First Deputy Commissioner, has worked to
reform the Health Management Division (“HMD”), which is charged with addressing all of the
requirements of the Action Plan in this area. Under the direction of the First Deputy
Commissioner’s team, a thoughtful and thorough assessment of HMD was conducted during
summer 2022 to identify deficiencies and inefficiencies. 30 The results of the evaluation revealed
significant mismanagement and corruption, as reported in the Monitor’s October 28, 2022 Report
(see pgs. 46-47). In short, poor supervision and staff practices, staff shortages, lack of
collaboration among HMD units, and a disconnect between the division and the facilities were
all impeding the management of staff leave benefits and modified duty statuses. These findings
led HMD to engage in a significant overhaul to improve practices. HMD has continued to refine
its practices. Outlined below are the steps HMD has reported it has taken since the reform effort
began:
•

HMD’s Organization and Staffing
o HMD Leadership: HMD is closely supervised by the First Deputy Commissioner.
An Executive Officer (who holds the rank of Assistant Deputy Warden) was
appointed in spring 2022 to manage the unit and reports directly to the First
Deputy Commissioner. 31 The Department has selected and hired a Chief Surgeon
who is scheduled to begin in April 2023. The Department is continuing to recruit
for an Assistant Commissioner of HMD.

30

As required by the Action Plan § A, ¶ 2(e).

31

As required by the Action Plan § A, ¶ 3(b)(iii).

25

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o HMD Staffing: HMD has almost 100 staff, about half of which are uniform staff,
working across 15 units within the Division. 32 HMD reports it is working to

reduce its reliance on uniformed staff. First, HMD intends to utilize civilian staff
for the Sick Desk and is working with HR to advertise and fill those positions.
HMD has also hired some new personnel including two nurses for the Case
Management Unit (now fully staffed with four nurses), a supervisor for the
Workers’ Compensation unit, and has extended an offer to a Chief Surgeon to
oversee HMD operations. Further, HMD continues to rotate uniformed staff
assigned to HMD out of the division every 90 days to reduce undue familiarity
that can lead to dishonest practices.
o Ongoing Evaluations of Practice: In order to ascertain its progress regarding
improved practices within the division, HMD conducted a subsequent evaluation
in January 2023 to ensure the new practices in place were having the intended
outcomes. The January 2023 evaluation found that the new practices have had the
desired impact on the way staff on leave and modified duty are managed and on
reducing the number of abuses previously seen, although more work remains.
This type of internal assessment is critical to maintaining the integrity of HMD.
•

Improving HMD’s Processes and Efficacy
o Improved Coordination Across HMD Units: The Department reports that

automated tools were created to allow certain processes to be completed within a
single module (rather than multiple manual steps) and that automatically
distribute information to the next HMD unit in the workflow (rather than manual
request/transmission of information). The use of technology also guards against
unauthorized manipulation of subsequent appointment dates or specific
dispositions.

o Reorganization: Units with complementary tasks (e.g., Investigations, Absence
Control Unit, Home Visitation Group and Disciplinary Units) will be reorganized

These 15 Divisions are Worker’s Compensation, Case Management, Absence Control, Home Visit
Group, Disciplinary, COVID-19, Investigative, Sick Desk, Medical Incompetence, Medical Records,
Toxicology, Clinic, F.I.S., Administrative/Personnel, and Security. Note, the Trials Division maintains a
separate group of staff responsible for adjudicating any disciplinary cases.

32

26

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into functional units to promote timely communication and swift action when
necessary.
o Restrictions on Access to Information: The Department reports that access to
HMD’s information management system was restricted and fortified to limit the
number of staff who are granted access and to ensure that only those staff who
need the information have access to it. These procedures are intended to prevent
the impropriety in record keeping that was found to have occurred in the past.
•

Initiatives to Reduce the Number of Unavailable Staff
o Preventing and Deterring Abuse of Leave: The various layers of scrutiny
described below provide additional safeguards to both prevent and deter staff
from taking unnecessary or excessive leave or remaining on modified duty when
they are able to return to full duty. Together, this scrutiny makes it more difficult
for staff to provide false information and creates more certainty that any abuse of
leave or modified duty will be detected.
o Increasing Scrutiny of Documentation and Medical Records: HMD has increased
scrutiny of those on sick leave and modified duty to ensure that staff provide

timely documentation and attend all scheduled medical appointments. In addition,
HMD proactively and routinely assesses staff on these statuses to ensure they are
appropriately applied. 33 As a result of these record reviews, staff who are no
longer qualified for a benefit were returned to full duty or their MMR level was
downgraded, which may allow them to work directly with incarcerated people. As
noted above, the ability to reschedule appointments to delay review has also been
curtailed through automation.
o Increasing Home Confinement Visits: The purpose of home confinement visit
protocols is to ensure that staff who report they are home sick are, in fact, at
home. The protocol for conducting home confinement visits has been streamlined,
which allows for more frequent visits, and more staff are now authorized to
conduct Home Confinement Visits. 34 Priority for visits is applied to staff who are

33

As required by the Action Plan § A, ¶ 2(f).

34

As required by the Action Plan § A, ¶ 2(d)(i).

27

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out sick for nine consecutive days, those with “chronic absence” designations and
those on “indefinite sick leave.” Violations are more frequently identified and
addressed, as discussed in more detail below.
o Increasing Referrals for Discipline of Staff Violating Protocols: HMD’s now
frequent scrutiny of medical documentation has exponentially increased its ability
to detect potential abuses and cases that may merit medical separation. Until
2022, the number of disciplinary actions brought to address potential violations
was minimal. As discussed more below, the Department’s efforts to hold staff
accountable for potential violations have increased exponentially. To support this
work, as noted in the Compliance Assessment (Staff Discipline & Accountability)
section of this report Disciplinary section of this report, the Trials Division has
doubled the number of staff assigned to work on these types of cases.
o Referrals to DOI: HMD’s increased vigilance about the quality of the

documentation has identified several instances of potentially fraudulent
documentation that may rise to the level of criminal misconduct. These cases have
been referred to DOI for investigation, as discussed further below. 35

o Identifying Staff with Consecutive AWOL: Beginning in 2022, HMD now

identifies staff who have been AWOL for 5 days or more so that they may be
separated pursuant to New York City Administrative Code § 9-113. Prior to 2022,
despite repeated inquiries from the Monitoring Team and for unknown reasons,
the Department had previously reported that separation under this law was not
possible.

o Identifying Staff with Chronic Absences: In order to discourage staff from
utilizing an unreasonable number of sick days, staff may be designated “chronic
absent” (i.e., those out sick for 12 days or more in a rolling 12-month period).
This designation triggers limits on various discretionary benefits and privileges
and impacts the staff’s ability to be promoted, thus serving as a deterrent to
excessive sick leave. The Department’s efforts to identify and manage staff so
designated has traditionally been poor. Case in point, only 100 staff were so

35

As required by the Action Plan § A, ¶ 2(g).

28

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designated in 2021, which is not credible given the volume of staff who were out
sick at the time. The number of staff placed on this status increased exponentially
in 2022, with over 1,000 staff now identified as chronically absent. This is a result
of HMD’s increased focus on staff who may meet this threshold. HMD has also
taken steps to ensure that the facilities are processing staff on these designations
properly. HMD reports that the identification staff who may be meet the chronic
sick leave standard has decreased toward the end of 2022, commensurate with the
reduction in the number of staff on sick leave.
o Evaluating Medical Facilities: HMD has started to visit medical facilities

frequented by staff to verify the documentation provided by the staff member
(e.g., confirming the date/time stamp) and to ensure that dispositions include a
signature from a licensed provider in order to be considered valid. This process
has identified that certain documentation may be fraudulent and cases have been
referred to DOI for investigation.

•

Policy Revisions
o Home Confinement Visits. 36 A revised policy was implemented in May 2022 and
is intended to deter the abuse of sick leave benefits by requiring staff to selfconfine at home and by providing for random visits to ensure staff are complying
with the policy. The protocols were revised to set more sensible requirements for
determining whether someone was home (e.g., fewer door knocks and fewer
phone calls) to increase the efficiency of the process.
o Sick Leave and Absence Control. 37 As noted above, many controls, if
appropriately deployed, are available to support adequate management of staff on
sick leave. The Department has taken the variety of steps described above under
the current 22-year-old policies. While demonstrable progress has been made in
practice, the Department must also update its policies on reporting sick leave and
absence control to codify improved practices and adequate controls. Policy
revisions have been slow despite the Monitoring Team’s repeated and consistent

36

As required by the Action Plan § A, ¶ 2(d)(i).

37

As required by the Action Plan § A, ¶ 2(d)(iii).

29

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prompting to stakeholders at all levels of the Department about the need to revise
this policy (and the Action Plan’s requirement). The Monitoring Team has
reviewed and provided comment on both policies. The policy needs to be
finalized and implemented in short order.
o Medically Modified/Restricted Status. 38 As above, progress has been made in

managing staff on MMR, but improved guidance and clarity about how and when
this status may be utilized is needed. The Monitoring Team has been briefed on
the proposed revision designed to reduce the use of MMR. Written procedures
need to be produced, finalized, and implemented in short order.

Accountability for Abuse of Leave & Modified Duty
The Department has several options for addressing staff who are chronically absent or
who have abused sick leave policies, including placing staff on unpaid leave, 39 non-disciplinary
separation proceedings, 40 disciplinary proceedings (known as Medical Incompetence), 41 and
suspensions. Further, the Department may refer staff to the Department of Investigations
(“DOI”) to investigate cases of suspected staff abuse of sick time or restricted status when the
conduct of the staff member appears to be criminal in nature. 42 The First Deputy Commissioner
routinely meets with DOI about the status of these cases to ensure that they are addressed.

38

As required by the Action Plan § A, ¶ 2(d)(ii).

Pursuant to New York Civil Service Law 72, a staff member may be placed on unpaid leave if they are
on “indefinite sick” or MMR status for a year or more for non-work-related reasons.

39

Medical and AWOL Separation is a non-disciplinary action (pursuant to Civil Service Laws §§ 71 to 73
and New York City Administrative Code § 9-113) to separate an employee who has been
cumulatively/continually out sick, unavailable to work, AWOL 5 days or more, or unable to fulfill work
duties for a significant period of time, generally one or two years.
40

Medical Incompetence is a disciplinary action in response to a variety of patterns of behaviors related to
the abuse of the sick leave benefit.

41

42

As required by the Action Plan, § A, ¶ 2(g).

30

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As outlined in more detail below, the Department has made significant efforts to reduce
staff absenteeism through increased accountability measures. Given the rarity of enforcement
historically, the Department’s current efforts reflect significant progress in holding staff
accountable for coming to work.
The outcome of the Department’s accountability efforts to address staff absenteeism are
listed below 43:
•

Medical Incompetence: 460 charges were brought for Medical Incompetence in 2022.
This reflects a 120% increase in cases from 2021.
o 476 Medical Incompetence cases were resolved from January 2022 through
February 2023 (the outcomes of these cases are subsumed in the bullets below).
o 461 Medical Incompetence cases are pending as of the end of February 2023 (this
includes the 288 cases that were pending as of October 2022 and is discussed
more below).

•

Suspensions: 402 staff were suspended for abuse of the sick leave/absence control
policies or for being AWOL (305 staff for home confinement violations and 97 staff for
being AWOL 44).

The 583 cases resolved between January 2022 and February 2023 were closed in the following
manner:

43

This also includes the cases required to be addressed by Action Plan, § A, ¶ 2, (f)(i).

In 2021, a total of 165 staff were suspended for being AWOL. The reduction in suspensions for AWOL
is likely due in part to fewer staff being AWOL.

44

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o Separations, Terminations, Resignations & Retirement: 244 staff were medically
separated, terminated, resigned, or retired from the Department. 45
o NPAs: 265 Medical incompetence cases resulted in an NPA, distributed as
follows:


1 reprimand/return to command;



43 cases settled with a term of limited or full probation for subsequent
violations, with no compensatory days deducted;



222 cases for compensatory time deducted and, in most cases, a term of
limited or full probation for subsequent violations including:
-

154 cases settled for compensatory time deductions of 5-15 days
(147 of the 154 cases also included a term of limited or full
probation for subsequent violations).

-

32 cases settled for compensatory time deductions of 15-30 days
(30 of the 32 cases also included a term of limited or full probation
for subsequent violations).

-

36 NPAs settled for compensatory time deductions of 31-80 days
deducted (32 of the 36 cases also included a term of limited or full
probation for subsequent violations).

o Return to Full Duty: 30 staff returned to full duty.

This includes staff who were separated pursuant to Civil Service Law §§ 71 or 73 (i.e., Medical
Separation); staff who were Medically Separated, and their Medical Incompetence disciplinary action was
put in abeyance should they return to the Department; staff who were separated pursuant to New York
City Administrative Code § 9-113 because they have been AWOL for 5 days or more; staff who were
terminated following a trial at OATH; staff who resigned; staff who retired in the midst of separation
proceedings, and staff who are deceased.

45

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o Administratively Filed Cases: 44 Medical Incompetence cases were dismissed.
•

Department of Investigation Referrals: Over 30 staff were referred to the Department of
Investigation for suspected abuse of sick leave or restricted status since 2022.
o 3 staff have pled guilty on federal charges of abuse of sick leave.

•

Chronic Absenteeism: 1,029 staff were identified as chronic absentees (compared to only
100 staff who were so identified at the beginning of 2022).

•

Status of Addressing Medical Incompetence Cases Pending as of October 2022: In the
Monitor’s October 28, 2022 Report, the Monitoring Team recommended that by April
30, 2023, the Department resolve the 386 Medical Incompetence cases that were pending
as of October 2022. The Department is on track to the vast majority of these cases by
April 2023. The status of these cases as of the end of February 2023 (with two more
months to go to meet the deadline) is below:
o 187 (48%) cases have closed.
o 85 (22%) cases are in the process of closing.
o 67 (18%) are scheduled for a trial.
o 45 (12%) cases are pending, including 17 cases involving staff on approved leave
(e.g., military leave or maternity leave).
o 2 (>1%) cases are under an independent medical review to determine whether a
disciplinary case may be merited.
Maximizing the number of available staff is an essential support for the overall goal that

all posts are covered, overtime is limited, units are properly supervised, and people in custody
have access to essential services. To that end, HMD and the Trials Division in particular, have
made significant progress in holding staff accountable for abuses of sick leave and modified

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duty, which has had the corresponding result that more staff are available to work than at any
time since the staffing crisis began in 2021. While the Trials Division is addressing more of these
cases than ever before, the closure rate is not keeping pace with the influx of new cases. The
number of pending Medical Incompetence cases has continued to grow and is larger now than in
October 2022. Accordingly, the pace of case closure must accelerate to ensure that all cases are
addressed in a timely manner. Further, given the increased number of cases pending, the Trials
Division tracking of these cases must be improved. To that end, the Monitoring Team has been
working with the Trials Division on a process for more reliable and consistent tracking of
Medical Incompetence cases.
Summary & Next Steps
The Department has made some important progress addressing the foundational problems
underlying its ability to properly staff its facilities so that it can provide for both safety and the
routine delivery of services. The addition of leaders from outside the Department has brought
sorely needed expertise in staff scheduling and deployment, and their efforts have already begun
to pay dividends. Coupled with the efforts of HMD to better manage staff absences and to hold
staff accountable when they abuse already generous leave benefits, the Department appears to be
on a trajectory capable of reversing the decades-old problems with managing its workforce. This
has resulted in improved working conditions for staff and reductions in the most concerning
staffing practices that left the Department operating as if it was understaffed, despite the large
number of staff on the payroll. This progress is extremely encouraging, but in several ways, only
represents the initial steps needed to fully remediate the deeply entrenched practice with staff
management and deployment. Current momentum must be maintained in order to fully

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implement and sustain the strategies that have recently been launched and those that must build
upon the steps taken to date.
To continue the positive trajectory, the Monitoring Team recommends the following
short-term priorities:
•

Recruit and hire a manager of the SMART unit.

•

Complete efforts to redeploy supervisors to the facilities and to ensure their presence
throughout evenings and weekends to properly oversee staff assignments and to provide
much needed on-the-ground coaching and guidance to officers.

•

Revise and implement the Sick Leave and Absence Control and the Medically
Modified/Restricted policies by May 15, 2023.

•

Upon resolving the pending Medical Incompetence cases identified in the October 2022
report by April 30, 2023, the Trials Division must then resolve the approximately 175 cases
that were brought since October 2022 and that are still pending. These 175 cases should be
closed no later than August 31, 2023.

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SECURITY PRACTICES & INDICATORS
The overall goal of the Consent Judgment is to eliminate the use of unnecessary and
excessive force and reduce the risk of harm in the jails. For this reason, the Department’s
security practices and indicators are at the heart of the reform effort. Monitoring this system over
the last seven years has revealed a system so dysfunctional that it is impossible to address the
specific security practices at issue in isolation. The issues underpinning the Department’s ability
to reform have created a polycentric problem, with a number of interrelated “problem centers”
for which the solution to each is dependent upon finding the solution to some, if not all, of the
others. Therefore, in order to achieve the goals of the Consent Judgment, changes across the
entire system are necessary, and are discussed in the various sections of this report. There is no
question that improved security practices and resulting improvement in facility safety is
undoubtedly the most important aspect of this work, but it is also the most elusive and will only
occur when each of the components discussed in this report come together. This particular
section addresses security and UOF practices, staff supervision, security initiatives, and an
analysis of trends in security indicators/outcomes for the Department as a whole and for
individual facilities. However, the many other issues discussed in the report also underpin this
work.
Significant work is underway to provide the necessary foundation to improve the
Department’s security practices. In particular, the infusion of external correctional expertise has
helped to identify priorities, guide practice, and address many of the dysfunctional foundational
issues. In the Monitoring Team’s experience, change will be gradual, and so it is not surprising
that even with this infusion of expertise various metrics regarding facility safety reveal mixed
results to date. For example, the average monthly UOF rate decreased for the first time in many
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years, staff were assaulted less often, and a small decrease in the rate of fights was evident in
2022. Further, the Department’s focus on two specific facilities, RNDC and GRVC, appear to be
yielding encouraging results. That said, the rate of UOF remains far too high (and higher than
when the Consent Judgment went into effect), the rate of stabbings and slashings is exorbitant,
and its contribution to an increase in the proportion of incidents involving serious injuries is
concerning.
The increasingly disordered environment and compounding staffing problems beginning
in 2020 further exacerbated existing poor practice and resulted in the constant disruption of even
the most basic services (e.g., recreation, laundry, commissary, barbershop), which created
additional frustration among the people in custody who were already stressed by the level of
facility violence, separation from their loved ones, and uncertainty in their court proceedings to
name a few. As the system begins to stabilize these issues have started to abate slightly. As
discussed throughout this report, while conditions in the Department have improved compared
with the very depths of the crisis in 2021, significant work remains as the conditions are
demonstrably worse than they were at the time the Consent Judgment went into effect.
The improvements witnessed in 2022 are encouraging given the long period of stagnation
and/or worsening conditions in this Department, but significant reductions in UOF and all forms
of violence must be achieved and sustained across time to fully address the conditions that gave
rise to the Consent Judgment.
Security and UOF Practices
Although some progress has been made in improving the operations of the jails and
reducing the rate of UOF from its apex in 2021, the work completed to date has not appreciably
improved the Department’s security practices and the Department’s problematic approach to
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using force Department-wide. For example, during the Monitoring Team’s routine site visits, it
was not uncommon for the Monitoring Team to enter a housing area with clear security lapses—
for example door manipulations and obstructions, and individuals congregated in unauthorized
areas—while a review of logbook entries revealed a recent supervisor’s tour that noted “no
issues.” Further, in 2022, facility leadership (via Rapid Reviews) identified that 48% of use of
force incidents involved procedural errors (e.g., failure to secure doors, failure to apply restraints
properly), some of which directly contributed to the circumstances that facilitated the incident.
This, coupled with the 16% of incidents that were determined to be “avoidable,” demonstrates
that even the Department’s internal analysis (which has some room for improvement) shows that
staff are not applying the requisite skill set and decision-making needed to decrease the use of
force rate. This is not to say that the initiatives discussed in this section will not ultimately
support improved practice, in fact, many are expected to do so and, in some cases, already have
improved practice.
There is much work to do in this area. This includes addressing poorly executed physical
restraints, a lackadaisical approach to basic security measures like securing doors and dispersing
crowds, and a general lack of situational awareness. Staff’s often hyper-confrontational
demeanor contributes to incidents spiraling out of control. Responses to events by the
Emergency Services Unit and an overabundance of staff means that force is often precipitated by
staff’s own behavior. These issues have been discussed in great detail in all Monitor’s Reports to
date and little improvement in overall staff conduct regarding the use of force has been
identified. The Monitoring Team’s extensive findings regarding poor security practices and
troubling use of force practices are essentially unchanged Department-wide, despite some
pockets of progress on individual initiatives and at individual jails as discussed further below.

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The reader is referred to prior Monitoring Team reports for more detail (see the Monitor’s March
16, 2022 Special Report at pgs. 7 to 24; the Monitor’s June 30, 2022 Report at pgs. 13 to 26; and
the October 28, 2023 Report at pgs. 56 to 81).
If, and only if, the various staff supervision and security initiatives discussed below are
properly implemented, the expected improvements should result in significantly lower levels of
violence and use of force, which in turn, should provide the space and time for staff to hone their
skills regarding de-escalating interpersonal conflict and dependable service provision.
Staff Supervision
The Department’s security failures are not generally centered on poor policy (although
improvements to policy and procedure are also necessary) but rather poorly informed habits and
the behavioral choices that staff make moment-to-moment. For this reason, strong leaders who
instantly recognize and are able to correct poor practice are needed. Supervisory failures at
multiple levels of uniform leadership have been and remain a consistent and pervasive
malfunction within the Department. An improvement in the quality of supervision at all levels of
the chain of command is imperative to elevate practice. Supervision is not simply advising staff
what to do, but also requires consistent expectations, frequent drill and practice, reinforcement
and recognition of improved practice, and accountability and discipline for those whose practice
does not evolve as required.
In this system, this goal is particularly difficult to achieve because the number of
supervisors is limited and because the supervisors generally lack the requisite perspective and
experience to guide their subordinates toward better practice. The Monitoring Team’s
observations over the past seven years indicate that supervisors at all levels have a limited
command of the restrictions and prohibitions of the Use of Force Directive, appear to act
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precipitously, and many ultimately end up contributing to or catalyzing the poor outcomes that
are of concern. They also fail to detect and fail to correct sloppy security practices that contribute
to many incidents. Their skill deficits are exacerbated by the fact that DOC has fewer levels of
supervisors in its chain of command than is seen in most correctional systems (see discussion in
the Monitor’s October 28, 2022 Report, at pgs. 78-80). Most areas in need of skill development
are basic correctional practices but infusing them to the point that they become reflexive practice
among thousands of staff and hundreds of supervisors is a monumental undertaking. It is why
embedding external correction expertise into this agency is so essential— the requisite expertise
does not exist at sufficient levels among veteran staff nor the many staff with only a few years of
service.
Progress has been made on this front since the Monitor’s October 28, 2022 Report. First,
the three well-qualified Deputy Commissioners of Staffing, Security, and
Classification/Operations and two Associate Commissioners of Operations have been hard at
work addressing these polycentric issues since the last report. The impact that these few
individuals have already had on practice confirms that the Department’s efforts to install
Assistant Commissioners of Operations (five individuals are scheduled to begin work in April
2023.) to serve as the commander of each of the individual jails (to essentially serve as the
Warden) 46 is a crucial next step and is expected to further improve practice.

As discussed in more detail in the compliance assessment of the First Remedial Order § A., ¶ 2., in
December 2022, the Court issued an order (dkt. 492) that permitted the Department to expand the pool of
candidates that may be considered to serve as Facility Wardens given the current compliment of staff
available to serve in the role was not sufficient and the Department’s attempts to develop alternative
leadership structures in the command were not workable.

46

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Below is a table of organization that depicts the new leadership structure.

Commissioner

Senior Deputy Commissioner [Vacant]*

Deputy Commissioner for
Administration ("Staffing
Manager")

DC for Classification, Custody
Management, and Facility Operations
("Classification Manager")

Associate Commissioner of Operations

Deputy Commissioner for Security
Operations ("Security Operations
Manager")

Associate Commissioner of Operations

Assistant Commissioner of
Operations* - AMKC

Assistant Commissioner of
Operations* - VCBC

Assistant Commissioner of
Operations* - GRVC

Assistant Commissioner of
Operations* - RNDC

Assistant Commissioner of
Operations* - NIC/WF

Assistant Commissioner of
Operations* - EMTC

Assistant Commissioner of
Operations* - RMSC

Assistant Commissioner of
Operations* - Courts

Since the Monitor’s October 28, 2022 Report, notable progress has been made in overall
staff assignment and deployment. Untangling poor conventions and replacing them with better
systems and routines has begun to alleviate the staffing crisis (evidence of improvement is
discussed in the Uniform Staffing Practices section of this report). The resulting expanded pool
of staff who can be assigned to facility posts and the reduced reliance on excessive overtime
should improve staff’s morale, reduce the level of chaos in the jails, and allow for improved
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service. These improvements to staff management and assignment will reportedly be followed in
short order by improvements to the assignment and span of control of Captains and ADWs in the
jails, which are essential steps toward improving staff’s security habits and moment-to-moment
choices. Naturally, Captains and ADWs will also require intensive coaching and guidance to
elevate their skills in staff supervision. Wardens and DWs are now receiving consistent guidance
and support from the two Associate Commissioners of Operations who were hired from outside
the DOC system and who possess years of experience in systems that have the sound
correctional practices that this Department so sorely needs. The future appointment of Assistant
Commissioners of Operations for each individual jail (who will report to the Associate
Commissioners of Operations) should further increase the network of support and guidance
available to uniform leadership in the jails. The extent to which these supervisory relationships
develop in a manner that supports improved practice down the chain of command remains to be
seen.
Another tangible step toward improved staff supervision is the efforts by the Staffing
Manager to alter the schedules of the Deputy Wardens and ADWs so there are more supervisors
available across shifts and throughout the week (including weekends). Another recent initiative
has started to better ensure that Tour Commanders (ADWs who are responsible for the on-theground supervision of each shift) more directly supervise their subordinates. Tour Commanders
have traditionally been stationed in an office in the administrative corridor of the jails. They were
supported by at least one uniformed assistant who was frequently tasked with touring the jail
while the Tour Commander remained in the office. In order to ensure that the Tour Commander
is physically located within and integrated into the operations of the jails, Tour Commanders will
be required to work from inside each facility’s control center (the central hub of the jail) instead

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of from an administrative office. Further, the assistants assigned to the Tour Commander will be
reassigned to posts working with incarcerated individuals. This transition has begun, and
completion is expected in April 2023.
Repositioning the ADWs to supervise each shift more closely is intended to support the
Department’s efforts to ensure that officers and supervisors are regularly touring their assigned
housing units. 47 Tours by line staff are essential for verifying the welfare of people in custody
and for addressing their concerns and service needs. Similarly, Captains’ tours are important for
detecting and correcting poor staff practice, for providing support to line officers and for
resolving any remaining concerns among people in custody. The initial step toward this goal is to
ensure that staff and Captains are conducting tours at the required intervals (30-minute intervals
for staff and multiple times per shift for Captains). Toward this end, the Department has
procured tour wands which, when tapped on a sensor affixed to the wall outside key locations in
the housing units, provide a record of the frequency of tours. A description of the efforts to
implement the use of tour wands was provided in the Monitor’s October 28, 2022 Report on pgs.
72 to 74. Since then, the policy was updated in early 2023 to expand the use of tour wands to
Captains assigned to celled housing areas and to staff within de-escalation units. The policy also
assigned the daily review of tour wand data to the Tour Commanders, who use this data to assign
discipline to staff when appropriate, but can also use this data as a means of more direct
supervision and oversight of their own staff’s touring practices. These enhancements, along with
improved oversight by facility leadership and routine audits by the Classification Manager’s
office, will be implemented in spring 2023.

47

As required by the Action Plan § A, ¶ 1(d).

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It must be emphasized that the tour wands are simply a tool to verify whether the required
tours are occurring, but they do not and cannot assess whether tours are of adequate quality.
RNDC has made some progress toward this goal, as the Warden reports regular reviews of
Genetec footage to determine whether staff actions during the tours suggest genuine efforts to
verify welfare and address concerns among people in custody. This illustrates why supervision is
so important and the requirement cannot be assessed by simply counting whether staff tapped the
sensors at the required intervals. Tours at the required intervals are, of course, an essential first
step, but are not sufficient for assessing whether staff are adequately addressing the needs of the
incarcerated population, utilizing sound security practices and mitigating the risk of harm to
people in custody. The Monitoring Team intends to scrutinize the use of the tour wands more
closely going forward and additional information will be included in future reports.
Overall, tangible and concrete steps have been taken to improve the supervision in the
jails. The most critical next step related to supervision is to hire and install the Assistant
Commissioners of Operations (five are scheduled to begin work in April 2023.) to lead each of
the individual jails.
Security Initiatives
The Deputy Commissioner of Facility Operations (who also serves as the Classification
Manager), the Deputy Commissioner of Security Operations (who also serves as the Security
Operations Manager), and the two Associate Commissioners of Operations, along with many
other individuals in the Department, have begun focusing directly on improving certain security
practices, using a two-pronged effort. 48 First, given their historically high rates of violence and

As required by Action Plan § D., ¶ 2(a).

48

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use of force, certain facilities (RNDC and GRVC) have been subject to a series of initiatives to
address the overall state of affairs (e.g. supplemental staffing, new tools for assigning and
deploying staff, increased supervision, increased focus on specific security practices, etc.).
Second, Department wide, there has been an increased focus on specific security practices,
including securing doors, removing obstructions, and preventing people in custody from
congregating around secure ingress/egress doors. Primarily this occurs via Wardens, DWs and
ADWs issuing clear expectations for Captains to focus on these issues, traveling to the housing
units themselves to verify that Captains identified and addressed any problems during their own
tours, and providing coaching, guidance and accountability if Captains have failed to do so. The
Department has also taken other steps to address problems regarding the use of the Emergency
Response Teams 49 (discussed in more detail in the Compliance Assessment (First Remedial
Order, § A. ¶ 6) section of this report and increased the number of searches 50 to obtain dangerous
contraband (data regarding searches and the volume of contraband seized is included in the
Appendix A of this report). Correctional Intelligence Bureau (“CIB”) has also been proactively
managing its intelligence sources to identify when an issue may arise, in an attempt to
proactively neutralize a situation. To that end, CIB has reported that it has convened meetings
with incarcerated individuals to identify points of tension that could lead to interpersonal conflict
and discussed how they may be best resolved.

49

As required by Action Plan § D., ¶ 2(c).

Searches are an essential component of any security operation to stem the flow of dangerous
contraband into a facility. In 2021, the Monitoring Team advised the Department to refine its practices to
reduce the level of confrontation, provide greater controls and to increase the effectiveness of search
procedures. These recommendations and a requirement to improve search procedures are included in the
Action Plan § D., ¶ 2(d).

50

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The Monitoring Team’s routine interactions with the Department’s new leadership team
reveal that they, through their own intuition and experience, have developed sound approaches
for addressing staff skill deficits and regularly identify the same deficiencies noted by the
Monitoring Team during their incident reviews and tours of the jails. There is certainly much
more work to do, but the areas of focus and initiatives that have been implemented are
reasonable first steps toward infusing the security focus that is the heart of a safe jail operation.
A critical area that has not yet been adequately addressed is the management of the
Emergency Services Unit, which continues to utilize problematic security practices that catalyze,
rather than prevent, a use of force and is staffed with individuals who may not be suited for the
position. These issues are long standing and with no appreciable change in practice. Leadership
of the division is lacking and requires oversight by an individual with a strong command of
sound correctional practice. Further, all staff currently assigned to the unit must be reevaluated
for fitness to serve in the unit, and those that remain must be re-trained promptly. Anything less
will continue to perpetuate the cycle of misconduct and problematic use of force by this unit.
These issues are further explored later in this report in the Compliance Assessment (First
Remedial Order, § A. ¶ 6) section of this report.
The Nunez Compliance Unit (“NCU”) has continued to develop critical and reliable
information about the Department’s efforts to address its security problems. Since December
2021 NCU has conducted nearly 100 security audits in the jails, a majority of which have
identified staff being off post, unsecured or manipulated cell door locking mechanisms, failure to
conduct timely tours of the housing units, poorly managed lock-ins, and people in custody in
unauthorized areas and crowded in vestibules. The Monitoring Team continues to encourage the
Department to utilize the information produced by NCU and to ensure NCU has sufficient

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staffing to conduct the broad range of audits required to fully support the Department’s efforts. 51
The Classification Manager and the Security Operations Manager are also recruiting staff for
their units to conduct direct, contemporaneous assessments of whether staff are adhering to the
various security-related initiatives currently underway. These undertakings should support the
overall effort to guide and advise staff on appropriate security practices.
Security Indicators
As noted in the introduction to this section, substantial changes to the use of force rate
and level of facility violence will occur only through the culmination and accumulation of the
many practices discussed throughout this report. The Monitoring Team, like all stakeholders, is
vigilant about detecting any changes to historical trends and whether they appear to be reversing
in a meaningful way or not. As discussed in more detail below, there are a few indicators that
suggest some progress may be occurring. In the Monitoring Team’s experience, institutional
reform is comprised of incremental improvements that combine to produce significant changes in
facility conditions over time, and thus this indicator of improvement is noteworthy. However, as
encouraging as it is to see certain decreases, the level of improvement is nowhere near the
magnitude required by the Consent Judgment, particularly as the level of stabbings and slashings
has reached an all-time high, and UOF remains at a level more than double the rate at the time
the Consent Judgment went into effect.

51

As required by the Action Plan § D, ¶ 4.

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•

Use of Force
The chart below shows that the total number of UOF (blue bars) and average monthly

UOF rate (yellow line) increased significantly between 2016 and 2021. 52 In 2022, for the first
time since the Consent Judgement went into effect, the average monthly UOF rate declined 15%
compared to the year prior (from 12.23 to 10.34) and is also lower than the average monthly use
of force rate in 2020. However, it remains more than double the rate at the time the Consent
Judgment went into effect.

Number and Rate of Uses of Force, 2016 - 2022
9000
11.3

8000
7000

7169

6000

5901

5000
4000

4652

3000

4780
3.96

8.21

14

12.23
8184

10.34
7005

6197

5.9

10
8

4.32

6
4

2000

2

1000
0

12

2016

2017

2018

2019
Number

2020

2021

2022

0

Avg. Rate

In addition to the frequency with which force is used, another key metric regarding
facility safety is the frequency of serious injuries during incidents that involve a use of force. A
use of force’s injury classification is derived from the most serious injury sustained by anyone

Given the fluctuation in the size of the incarcerated population, rates are the most useful metric because
they neutralize these changes. Throughout this document, average monthly rates per 100 people in
custody were calculated using the following formula: average monthly rate = ((total # events in the time
period/number of months in time period)/average ADP for the time period) *100.

52

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Case 1:11-cv-05845-LTS-JCF Document 517 Filed 04/03/23 Page 53 of 246

involved in the incident (person in custody or staff). In other words, it does not count all injuries
sustained in an incident but rather classifies the incident by the most serious one. The chart
below shows that the proportion of UOF with no injury (Class C; blue bar) has sustained an
increase since 2016 (from about 63% in 2016 to about 82-83% in 2021 and 2022). This is
undoubtedly positive. However, the chart also shows that the proportion and number of UOF
with the most serious injuries (Class A; grey bar/red text) has increased during this same time
period (from about 2% in 2016 to 6% in 2021 and 2022). This translates to an increase of at least
350 additional serious injuries (because a single incident may involve multiple serious injuries)
in 2021 and 2022 compared to 2016.

Proportion of Class A, B and C Injuries, 2016 - 2022
2022

5790

781

434

2021

6697

1033

464

2020

5059

2019

1648

5355

2018

2016
0%

10%

20%

30%

74

1627

2950
40%

50%

60%

Class C

Class B

Class A

70%

80%

166

134

1743

2903

178

136

1894

3871

2017

•

960

90%

100%

Stabbings and Slashings
The number and rate of stabbings and slashings have increased exponentially over the

past two years. The chart below shows the alarming increase in the total number and average
monthly rate of stabbings and slashings in 2021 and 2022 compared to previous years.

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Number and Rate of Stabbing/Slashing, 2016 - 2022
0.8

500
450

468

400

420

350

0.69

0.63

0.7
0.6

300

0.5

250

0.4

200
150
100

159

0.14

0.14
132

50
0

2016

2017

0.1

0.12
96
2018

0.22

121

121

2019

2020

Number

0.3
0.2
0.1
2021

2022

0

Rate

Within 2022, the rate of stabbings and slashings was even higher during the first part of
the year (0.77 in January-June 2022), but the annual rate was tempered by a decrease in the
second part of the year (0.62 in July-December 2022). These rates remain about five times higher
than the rate in 2016 and are simply exorbitant.
•

Fights Among Incarcerated People
The average monthly rate of fights (yellow line in the chart below) has also been

significantly higher in recent years. Since 2020, the average monthly rate of fights has fluctuated
but has not meaningfully changed. It still remains almost 70% higher than the average monthly
rate of fights in 2016 (8.62 versus 5.11).

50

Case 1:11-cv-05845-LTS-JCF Document 517 Filed 04/03/23 Page 55 of 246

Number and Rate of Fights, 2016 - 2022

7000
6000

9.32

8.54
6007

5921

5835

9
8
7

5.35

5.11

6237

6.21

5000
4000

6151 6.94

6253

10
8.62

4659

6
5

3000

4
3

2000

2

1000
0

1
2016

2017

2018

2019
Number

•

2020

2021

2022

0

Rate

Assaults on Staff
The average monthly rate of assaults on staff decreased significantly during 2022 as

shown in the chart below. The Department has always collected data on assaults on staff that
occur during incidents involving a use of force (blue bar). The green line in the chart below
shows that in 2022, the average monthly rate of assaults on staff with a UOF decreased 30%
from its level in 2021 (1.18 versus 1.67), though it remains higher than 2016. In 2020, the
Department began collecting data on assaults on staff that occur without a use of force (orange
bar). The yellow line in the chart shows an even larger decrease in the average monthly rate of
this type of assault (46%, from 2.26 to 1.22). In the Monitoring Team’s experience, decreases in
the rate at which staff are assaulted can serve as a motivating factor for bringing staff back to
work who had previously been out on sick leave or on modified duty.

51

Case 1:11-cv-05845-LTS-JCF Document 517 Filed 04/03/23 Page 56 of 246

Number and Rate of Assaults on Staff, 2016 - 2022
1600
1400

2.00

1.67
1.51

1109

1000

600

1515

1.91

1200

800

2.50

2.26

1.25

978
862

842
0.72

825

0.97

1042

1115

1.22
1.18 799 823

0.78

400

1.50

1.00

0.50

200
0

2016

2017
AOS with UOF

2018

2019

AOS w/o UOF

2020
Rate with UOF

2021

2022

0.00

Rate without UOF

The analysis of Department-wide statistics continues to show rates of use of force and
violence at much higher rates than in 2016, but also revealed some very modest but long-awaited
decreases in 2022 after a long period of stagnation.
Facility Specific Initiatives
Throughout its seven-year history monitoring the conditions of this Department, the
Monitoring Team has given increased scrutiny to certain facilities with exceptionally high rates
of violence and uses of force. The Department has likewise taken this approach, focusing on
RNDC (where the majority of people aged 21 and younger are housed) and GRVC (where the
Department houses the largest proportion of individuals with the highest propensity for
violence). As discussed below, one of the facilities (RNDC) has recently showed some
improvement in safety and GRVC has received some additional targeted support in an effort to
address its unsafe conditions.

52

Case 1:11-cv-05845-LTS-JCF Document 517 Filed 04/03/23 Page 57 of 246

•

RNDC
RNDC has housed about 75% of those aged 21 and younger who are committed to the

Department’s custody since GMDC closed and “Raise the Age” 53 went into effect in late 2018.
This age cohort has particularly high rates of violence and uses of force when compared to their
older counterparts. While the age composition has varied significantly over the years, currently,
RNDC’s average daily population of about 800 people is about half those aged 22 and older and
half those aged 21 and younger. The quantitative data discussed in this section clearly illustrates
the reason that RNDC has received increased scrutiny over the years and was often the first of
the jails to roll out various initiatives designed to improve staff practice, reduce violence and
increase safety. These initiatives include:
•

Commissioner's Violence Reduction Plan. RNDC was the first facility targeted by the
Commissioner’s Violence Reduction Plan in early 2022. 54 This included, among other
things, supplementary staffing to support housing unit officers, redistributing those
affiliated with SRGs to prevent their concentration in individual housing units, and
utilizing special teams to increase the frequency of searches for dangerous contraband.
These practices have been sustained and/or adopted by RNDC’s own security teams.

•

New Tools for Staff Assignment and Deployment. As discussed in the Uniform Staffing
Practices section of this report, RNDC is also the first site to implement many of the
Department’s new staffing innovations and protocols. Implementation is far too recent to
assess the impact, but the fact that the new strategies have been put into practice is
encouraging given the previous decades of convoluted and often self-defeating staffing
practices.

In 2017, New York State passed the “Raise the Age” (RTA) law that raised the age of criminal
responsibility to 18-years-old and created a new legal status for youth called “Adolescent Offenders,”
(AOs), which is defined as 16- and 17-year-olds who are charged with a felony-level offense. RTA was
implemented in stages, with the AO category applying to any 16-year-old charged on or after October 1,
2018, and any 17-year-old charged on or after October 1, 2019. RTA also prohibited housing 16- and 17year-olds on Rikers Island as of October 1, 2018.
53

54

As required by Action Plan § A, ¶ 1(a).

53

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•

Cell Door Replacement. A total of 850 new cell doors have been installed at RNDC as of
March 31, 2023 55 and additional information regarding the installation of cell doors is
provided in the Appendix A to this report.

•

Post-Incident Management. 56 The Department developed a post-incident management
protocol for RNDC to better isolate the perpetrators of acts of violence, limit the potential
to exchange/abandon contraband, efficiently search the individuals involved, and transfer
those involved to more secure locations as appropriate. While the facility has begun to
better structure its response, NCU’s audits suggest these improvements are often offset
by the failure to follow the basic steps of the policy, as discussed in more detail below.

While there is clearly more work to be done, both the Monitoring Team’s site visit
assessments and NCU’s audits suggest that RNDC has begun to stabilize, with noticeably
improved practice and a more orderly environment. In particular, NCU’s audits of RNDC have
found fewer staff off-post, more structured and controlled responses following violent events,
more frequent searches with better management of individuals, more expeditious processing of
perpetrators of violence through intake for body scans and medical assessments. That said, NCU
also identified several areas in need of improvement including more meticulous search protocols
given the frequency with which weapons are not recovered following a stabbing/slashing;
ensuring that perpetrators from the same incident remain separated (i.e., are not placed in the
same intake pen); and improved situational awareness to ensure staff are present and cognizant
of all acts of violence that may occur.
These initial practice improvements have begun to make an impact on facility safety, as
shown in the metrics discussed below. On each metric (use of force, stabbings/slashings, and

55

As required by the Action Plan § A, ¶ 1(c) and § D, ¶ 5.

56

As required by the Action Plan § D, ¶ 2(h).

54

Case 1:11-cv-05845-LTS-JCF Document 517 Filed 04/03/23 Page 59 of 246

fights), RNDC’s annual average monthly rates decreased in 2022 and in all cases, these annual
rates obscure even further decreases when comparing the first half of the year to the latter half.
With regard to the use of force, the average monthly rate decreased 7% from 2021 to
2022 (13.5 to 12.5), but this annual data point obscures a more substantial change as illustrated
in the table below the chart.

RNDC Number and Rate of UOF, July 2018 - 2022
28.1

1400
1200

30
1176

1000

1320

20.9

800
600
400

743

667

25
13.5

12.1

1131
12.5

15
10
5

200
0

20

Jul-Dec 2018

2019

2020
UOF

2021

2022

0

Rate

In the first part of 2022, the facility’s average monthly UOF rate increased significantly
as the facility initiated its strategy to disperse those affiliated with Security Risk Groups (“SRG”)
across a larger number of housing units such that no one group dominated a single unit, along
with deploying more frequent searches to detect and seize dangerous contraband. As the facility
stabilized, use of force decreased in the latter part of the year. The average monthly use of force
rate from July-December 2022 was 35% lower than in January-June 2022 (9.8 versus 15.1). Thus
far in 2023, this lower use of force rate has been sustained (January-February 2023 average
monthly rate is 8.2).

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Case 1:11-cv-05845-LTS-JCF Document 517 Filed 04/03/23 Page 60 of 246

Use of Force at RNDC
January 2022 to February 2023
Months

Total # UOF

Average/month

ADP

Rate

January-June 2022

653

108.8

727

15.0

July-December 2022

478

79.7

812

9.8

January-February 2023

128

64

783

8.2

The rate of serious interpersonal violence in the form of stabbings or slashings followed a
similar pattern. Compared to 2021, the average monthly rate of stabbings/slashings decreased
18% in 2022 (from 1.41 to 1.16).
RNDC Number and Rate of Stabbing/Slashing, July 2018 - 2022
160
140
120
100
80
60
40
20
0

1.41

1.16
138
107
0.43
13

10
Jul-Dec 2018

2019

0.24
15

0.23
2020
Number

2021

2022

1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0

Rate

As shown in the table below, the rate of stabbing/slashing in the first part of the year
remained high as the Commissioner’s Violence Reduction Strategy was implemented. The
impact of these strategies became apparent in the latter part of the year, with the rate of
stabbings/slashings decreasing 53%, from 1.6 to 0.76. Although a spike in stabbings/slashings
occurred in December 2022, it was fortunately short-lived, and even further reductions in the rate
were witnessed in January-February 2023 (down to 0.51).

56

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Stabbings/Slashings at RNDC
January 2022 to February 2023
Months

Total # S/S

Average/month

ADP

Rate

January-June 2022

70

11.7

727

1.6

July-December 2022

37

6.2

812

0.76

January-February 2023

8

4.0

783

0.51

The rate of fights at RNDC is also on a downward trend. The average monthly rate in
2022 was 17% lower than 2021 (9.82 versus 11.8) and was the lowest it has been since 2018
when this population was first moved to RNDC.

RNDC Number and Rate of Fights, July 2018 - September 2022
1400
1200
1000
800
600
400
200
0

21.77

25

21.35
1199

1158

11.22

20
11.8

9.82 10

699
512
Jul-Dec 2018

15

906

5
2019

2020
Fights

2021

2022

0

Rate

As shown in the table below, the average monthly rate has decreased further since the
beginning of 2022, from 10.43 to 9.26 and to 6.96 during the first two months of 2023.
Fights at RNDC
January 2022 to February 2023
Months

Total #
Fights

Average/month

ADP

Rate

January-June 2022

455

75.83

727

10.43

July-December 2022

451

75.17

812

9.26

January-February 2023

109

54.5

783

6.96

The short-term results following the careful implementation of the Commissioner’s
Violence Reduction Plan by RNDC’s leadership suggest that the Plan and other security related

57

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initiatives are beginning to accomplish the long-term goal of reducing violence and disorder. The
Compliance Assessment (First Remedial Order § A.) section of this report discusses RNDC’s
progress toward addressing ¶ 1 of § XV. Safety and Supervision for Inmates Under Age 19, and
finds that the facility’s progress, if sustained, may soon warrant removal from Non-Compliance.
•

GRVC
Like RNDC, GRVC has received special attention from the Monitoring Team (and

therefore, by the Department) because of its high rates of use of force and violence and,
relatedly, because the largest number of individuals who engage in serious violent behavior are
housed in this facility. For these same reasons, the Commissioner expanded the Violence
Reduction Plan to GRVC during late summer 2022. 57 This included the SRG blending strategy
and increased tactical search operations, although GRVC did not receive the same supplement to
its housing unit staffing levels. GRVC’s incarcerated population responded to these changes with
more violence and for a more sustained period of time than was observed at RNDC. As a result
of the continued level of violence and disorder, a new leadership team was installed toward the
end of 2022. An Associate Commissioner of Operations was also assigned to guide and support
the facility’s new Warden.
Improvement in facility conditions did not occur as quickly at GRVC as it did at RNDC.
A comparison of outcomes from early and late 2022 suggest that conditions worsened during the
latter part of 2022 as the general state of instability continued. However, as discussed in detail
below, improvements in facility operations and key metrics were observed during the early part
of 2023.

57

As required by Action Plan § A, ¶ 1(b).

58

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First, GRVC’s average monthly use of force rate reached an all-time high in 2022 (17.8;
yellow line in the chart below) and was nearly three times as high as the use of force rate in 2016
(6.91).

GRVC Number and Rate of UOF, 2016 - 2022
1600
1400
1200
1000
800
600
400
200
0

16.19

13.26
9.28
6.91

6.42

556

522

2016

2017

15.22
1272

1218

1092

17.8
1445

20
15
10

742

5

2018

2019
UOF

2020

2021

2022

0

Rate

The table below shows that the average monthly use of force rate has varied a bit over the
past 14 months, increasing a bit in the second part of 2022 (from 16.7 to 18.5) and then
decreasing about 35% thus far in 2023 (to 12.0). The facility population has also increased
considerably during this time, with the average daily population increasing about 30% (from 622
to 816).
Use of Force at GRVC
January 2022 to February 2023
Months

Total # UOF

Average/month

ADP

Rate

January-June 2022

621

103.5

622

16.7

July-December 2022

824

137.3

743

18.5

January-February 2023

196

98

816

12.0

Similarly, GRVC’s rate of serious violence in the form of stabbings and slashings
reached its highest point in 2022 and was about 13 times higher than the rate in 2016 (1.92
versus 0.15) and was 85% higher than the 2021 rate (19.2 versus 1.04).

59

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GRVC Number and Rate of Stabbing/Slashing, 2016 - 2022
200
150

157
1.04

100
50
0

2.5

1.92

0.15

0.14

0.12
12

2016

0.3
11

10
2017

2018

0.56
24

2019
Number

2020

1.5
1

87

42

2

0.5

2021

2022

0

Rate

The annual rate obscures the fact that the rate in the latter part of the year was
significantly higher than the early part of 2022 (2.22 versus 1.55, or an increase of 43%). The
rate dropped significantly in early 2023, but with only two months of data to assess, the extent to
which this will be the beginning of a downward trend is not yet known.
Stabbing/Sashing at GRVC
January 2022 to February 2023
Months

Total # S/S

Average/month

ADP

Rate

January-June 2022

58

9.7

622

1.55

July-December 2022

99

16.5

743

2.22

January-February 2023

20

10

816

1.23

Finally, GRVC’s rate of fights was slightly higher (8%) than 2021, with no major
differences between the first part of the year and the latter part. The average monthly rate of
fights decreased about 15% in early 2023—while the number of fights per month was similar,
the increase in the size of the facility’s population means the rate was lower.

60

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GRVC Number and Rate of Fights, 2016 - 2022
700
600
500
400
300
200
100
0

8.7

7.54

6.26
3.32
267

263

2016

2017

7.39
605

658

600
3.23

6.87

8
6

572

501

10

4
2

2018

2019
Fights

2020

2021

2022

0

Rate

Fights at GRVC
January 2022 to February 2023
Total #
Fights

Average/month

ADP

Rate

January-June 2022

275

45.8

622

7.37

July-December 2022

330

55.0

743

7.40

January-February 2023

102

51.0

816

6.25

Months

The Monitoring Team remains concerned about the level of violence at GRVC and is
closely watching the implementation of various violence reduction tactics and the early pilottesting of the revised restrictive housing model (which is housed at GRVC, and discussed further
in the Managing Incarcerated Individuals Following Serious Incidents of Violence section of this
report). However, the Monitoring Team’s recent site visits identified noticeable improvements,
including fewer individuals in corridors and unauthorized areas, improved sanitation and
building conditions (e.g., power washed and painted areas, refinished floors), less tension in
general population housing areas, and higher staff morale and buy-in for recent security
initiatives. Further, given the concerning conditions at GRVC, the Monitor has personally
reviewed all reported incidents (e.g. use of force, stabbing and slashings, assaults, log book
entries, etc.) at GRVC that are reported via the Central Operations Desk from October 2022 to

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Case 1:11-cv-05845-LTS-JCF Document 517 Filed 04/03/23 Page 66 of 246

date. The Monitor has observed a steady and substantial improvement in the GRVC staff’s
ability to stabilize the facility and reduce the overall disorder seen during 2022, which appears to
be a direct result of the guidance of the Deputy Commissioner of Facility Operations,
Classification and Custody Management and his team. Most importantly, as of the filing of this
report, overall incidents of disorder have been greatly reduced at GRVC, including the number of
slashings and stabbings. Notably, since the revised restrictive housing model pilot program was
initiated in February 2023, there have been no reported slashings or stabbings in the ESH
housing units for either level.
Current State of Affairs & Moving Forward
The Department has a dedicated focus on security matters and a new cadre of wellqualified leaders with a frequent presence in the jails to develop the skill set of uniformed staff at
all levels. This type of eyes-on, hands-on supervision is what is needed to develop the skill
mastery, situational awareness, and workplace culture that is necessary to meet the requirements
of the Consent Judgment. For this reason, the rapid recruitment and hiring of additional Assistant
Commissioners of Operations is essential to accelerate progress in all jails, particularly GRVC
and AMKC. This will enable the Department to leverage the advancements slowly being made in
other areas (e.g., staffing, classification, restrictive housing). Further, dedicated focus to
reforming the ESU is needed with a change in direct leadership of the unit, assessment of all staff
assigned to the unit (in either a permanent or temporary capacity), and re-training to ensure the
practices utilized by ESU align with the requirements of the Court’s Orders and sound
correctional practice.
In short, granules of progress are evident, but the levels of use of force and facility
violence remain exorbitant and facility environments remain volatile and deeply dysfunctional.
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The Monitoring Team remains very concerned about the continuing risk of harm which will only
abate via a sustained and deepened effort.

63

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DEATHS OF INDIVIDUALS IN CUSTODY
Calendar year 2022 marked the highest rate of deaths in custody at the Department in at
least the past ten years. The Monitoring Team is alarmed by the number of deaths among
individuals in custody, particularly those due to suicide and drug overdoses. Since the Monitor’s
October 28, 2022 report, three individuals have died in custody (one of whom died in 2023). In
this section of the report, the number and rate of in-custody deaths is examined, followed by a
discussion of investigations of in-custody deaths, and finally an update on the work the
Department has been engaged in to address the Monitoring Team’s recommendations 58
regarding self-harm and addressing in-custody deaths.
In-Custody Deaths & Causes
Concerningly, deaths in custody have increased in jail systems across the country,
especially since the COVID-19 pandemic in 2020. 59 This is certainly true in the New York City
jails which have seen an exponential increase in in-custody deaths during the last few years. The
chart below compares the rate of death in New York City, San Diego County, and Los Angeles
County jails, which demonstrates an overall increase in the rate of death in a few large
metropolitan jails. 60

58

See Monitor’s October 28, 2022 report at pgs. 29 to 31.

See Monitor’s October 28, 2022 report at pgs. 17 to 20. See also Maher, K., & Frosch, D. (2022,
October 18). Inmate suicides rose sharply in U.S. prisons, jails during pandemic. The Wall Street Journal.
Retrieved October 25, 2022, from https://www.wsj.com/articles/u-s-prisons-jails-see-jump-in-suicides11666098966?st=4ylpfw6it2so528&reflink=desktopwebshare_permalink.
59

Sources: Interim Monitor Report in the matter U.S. v. Miami Dade, et. al., 13-cv-21570 (S.D.Fla.)
dated August 12, 2022 (dkt. 246) pg. 7; Los Angeles County Office of Inspector General. (2022). Reform
and Oversight Efforts: Los Angeles County Sheriff’s Department, April to June 2022, pgs. 14-17; Los

60

64

Case 1:11-cv-05845-LTS-JCF Document 517 Filed 04/03/23 Page 69 of 246

Rate of Death in Custody, 2013 to 2022
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
NYC
San Diego
Los Angeles

2013
2.05
2.16
1.82

2014
0.92
3.01
1.43

2015
1.11
2.41
1.23

2016
1.53
2.8
1.2

2017
0.65
2.64
1.53

NYC

San Diego

2018
0.95
2.71
1.77

2019
0.41
2.84
2.17

2020
2.42
2.86
2.88

2021
2.87
4.58
3.77

2022
3.46
4.69
2.39

Los Angeles

The Department’s data on the number and causes of deaths from January 2015 to March
31, 2023, is presented below and shows that the number and rate of in-custody deaths by suicide,
overdose, and a variety of physical health problems has increased significantly during the past
few years. In 2022, the number of individuals who died in custody (n=19 61) was the highest since
2013, when 24 individuals died in custody. Of particular note, the number of deaths by suicide
and drug overdose have increased during the past two years. In 2022, 5 committed suicide and 6
died via overdose and 1 suspected overdose (pending confirmation from the OCME). A
summary of the practice failures across the agencies involved in managing incarcerated

Angeles County Sheriff’s Department. (2022) Custody Division Population Quarterly Report, April-June
2022. pg.3; San Diego County’s Sheriff’s Department (2022). San Diego County Sheriff’s Department
Daily Population Report, 10/28/2022; and Davis, K. And J. McDonald. (2022). “Fight among detainees
at Otay Mesa jail results in 19th death this year, marking grim record.” The San Diego UnionTribune, October 6, 2022.
61

This includes two individuals who died after they had been compassionately released.

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Case 1:11-cv-05845-LTS-JCF Document 517 Filed 04/03/23 Page 70 of 246

individuals that likely contributed to the high rate of death in custody can be found in the
Monitor’s October 28, 2022 report at pgs. 21 to 22.
Thus far in 2023, one person has died while in New York City jails. Appendix A of this
report lists the name and date of death for each individual who has died in custody since
November 2015. 62

2015

NYC DOC Causes of Death,
2015 to March 31, 2022
2016 2017 2018 2019 2020

2021

Accidental

2022

2023

1

COVID-19

Total
1

3

2

2

4

3

43

4

6

13

4

5

15

Drowned

1

1

Pending OCME
Confirmation

1

Medical Condition

9

Overdose
Suicide

2

11

4

2

1

2

7

3

1

1

Undetermined Due to
Death Outside DOC
Custody

4 63

Undetermined by OCME
Total

1
11

15

6

2

5

1

2

8

1
8

3

11

2

2
16

19

1

90

The table below shows DOC’s mortality rate from January 2010 to March 31, 2023. The
sharp increase in the mortality rate between 2020 and 2022, is troubling. The mortality rate in
2022 was the highest in over a decade and more than double the rate in 2016, at the inception of

62

This list also includes any individual who was compassionately released and then died in 2021 or 2022.

4 of the 11 individuals who passed away in 2020 were not technically in DOC custody at the time they
passed away as they were participating in programs in the community and were not under the supervision
of DOC staff at the time of their death and were not physically in the Department’s custody (i.e., they
were participating in Brooklyn Justice Initiatives, Specialized Model for Adult Reentry and Training
(SMART), and Work release programs). The cause of death for each of these individuals is not known
and categorized as “Undetermined.”
63

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Case 1:11-cv-05845-LTS-JCF Document 517 Filed 04/03/23 Page 71 of 246

the Consent Judgment. So far in 2023, one person has died in custody and the mortality rate has
decreased accordingly. This does not mean that the risk has fully abated—the Department still
must take a number of steps to prevent the situations leading to deaths in custody over the past
several years.
Mortality Rate
2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020

2021

2022

2023

Annual
ADP

13,026

12,421

12,083

11,692

10,913

9,890

9,802

9,224

8,397

7,388

4,543

5,574

5,639

5,912

Number
of Deaths

17

12

21

24

10

11

15

6

8

3

11

16

19

1

Mortality
Rate

1.31

0.97

1.74

2.05

0.92

1.11

1.53

0.65

0.95

0.41

2.42

2.87

3.37

0.17

Note: Mortality Rate per 1000 people in custody uses the following formula: Rate = (# of deaths/# of people in custody)*1000

Investigations of In-Custody Deaths
A key component to understanding the causes of death in custody and ensuring adequate
accountability for lapses and/or failures in practice is a thorough assessment of each occurrence.
As with most issues related to this agency, oversight with respect to in-custody deaths is
complicated and convoluted. Investigations of in-custody deaths are disjointed, untimely and/or
unavailable and therefore do not help to identify systemic failures that, if addressed, could reduce
the risk of future in-custody deaths. Each agency’s review has different parameters and scope of
inquiry. For instance, some investigations only assess whether criminal conduct occurred, while
others assess whether practices conformed to applicable policy. A complete discussion of this
web of responsibility is provided in the Monitor’s October 28, 2022 report at pages 22 to 26.

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The current status of the investigations across the relevant agencies is shown in the table
below. As shown below, many investigations of deaths that occurred in 2021 and 2022 are still
pending. With respect to DOC’s internal investigations of the deaths in 2021 and 2022, ID has
completed 11 investigations (8 from 2021 and 3 from 2022). The majority of investigations
remain pending because ID is awaiting clearance for completion until after the external
investigations are complete). 64

Year

Total
Deaths

2023
2022
2021
2020

1
17
16
11

Status of Investigations by External Agencies
January 2020 to March 2023
Office of Chief
SCOC Completed
AG Completed
Medical
Investigations
Investigations
Examiner
0
0
0
1
2
16 65
4
10 66
14 67
3
7 68

BOC
Completed
Investigations
0
12
10
1

One criminal prosecution related to an in-custody death in 2020 concluded during the
current Monitoring Period. On March 14, 2023, a (now former) Captain was found guilty of one
count of negligent homicide for preventing officers from saving the life of an incarcerated person
who died by suicide in November 2020.

ID reported that they must receive clearance from the AG’s office, as well as the relevant District
Attorney’s Office and the Department of Investigation before proceeding with an internal investigation.
64

2 individuals that died were not in physical DOC custody at the time of their death so the OCME will
not determine the official cause of death in those cases.

65

The Attorney General’s Office only began investigating in-custody deaths on April 1, 2021, so the
Attorney General’s office would only investigate 13 of the 16 deaths that occurred in 2021.

66

2 individuals that died were not in physical DOC custody at the time of their death so the OCME will
not determine the official cause of death in those cases.
67

4 individuals that died were not in physical DOC custody at the time of their death so the OCME will
not determine the official cause of death in those cases.

68

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Unfortunately, none of the agencies responsible for investigating the causes of in-custody
death in New York City jails has a record of producing close-in-time analyses of contributing
factors which means that the jails and people in custody have yet to benefit from this oversight.
In fact, the diffusion of responsibility may contribute to the apparent lack of urgency felt by any
single agency. This makes the Department’s efforts to address the gaps in understanding of
contributing factors and to enact practice improvements that much more important.
DOC’s Efforts to Address the Monitoring Team’s Recommendations to Prevent Self-Harm and
In-Custody Deaths
The Department has taken a number of important steps to improve its practices regarding
managing people at risk of engaging in self-harm and to prevent in-custody deaths. The
Department reports the following:
•

Retained an External Consultant: The Department retained a well-regarded expert to
provide consultation on these matters, with a particular focus on mortality reviews.

•

Appointed a Deputy Commissioner of Health Affairs: The Commissioner appointed a
well-qualified individual to serve in the role of Deputy Commissioner of Health Affairs
in February 2023.

•

Developed and Convened a Mortality Review Committee: With the guidance of the
external consultant, the Department, Correctional Health Services, and counsel from the
Law Department will conduct In-Custody Death Joint Assessment and Reviews (“JARs”)
following all in-custody deaths. The new process fortifies the previously utilized JAR
process.
o Membership of the JAR Committee: The JAR Committee’s membership includes
representatives from the Department, Correctional Health Services, and a
representative of the Corporation Counsel’s office. This brings a much-needed
multi-disciplinary perspective to the process.
o Structure of Review: The JAR Committee will meet at least three times following
an in-custody death. This will include:


Two-Day Executive Review (to be held within two business days following
an in-custody death): The goal of this initial review is to share immediate
factual information and to review the circumstances surrounding the
person’s death as known at that time. Immediate remedial action or
preventive action will be taken at that time for identified critical issues.

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

Seven-Day and Thirty-Day Executive Review (to be held within seven and
thirty business days following an in-custody death): The goal of these
reviews is to share and discuss additional findings and discuss the status of
any previously identified remedial or preventive measures taken since the
previous review. Some longer-term corrective actions may require the
JAR Committee to create a separate working group to assess complex
issues, develop remedial measures and oversee implementation, all of
which will be reported back to the full committee.

o JAR Implementation: The JAR has convened to review the in-custody death that
occurred in early 2023. The Monitoring Team intends to evaluate the JAR’s
functioning and outcomes and will report those findings in subsequent reports.
•

Convened Suicide Prevention Task Force: the Department developed a Suicide
Prevention Task Force in fall 2022 to begin evaluating these issues. The Task Force was
originally chaired by the Deputy Commissioner of Administration, who has expertise in
suicide prevention (and is also the Staffing Manager). Effective March 2023, the Task
Force is now chaired by the newly-appointed Deputy Commissioner of Health Affairs.
Task Force members include the Deputy Commissioner of Administration, Deputy
Commissioner of Security, Deputy Commissioner of Adult Programming & Community
Partnerships, Assistant Commissioner of Operations, Assistant Commissioner of
Strategic Initiatives, an Executive Director of Health Affairs, Director of Data
Management for Health Affair, uniform staff representatives, and representatives from
H+H.
•

The Task Force has undertaken the following tasks:
o Provided suicide prevention training for staff working with the incarcerated
population: The Department reports that as of March 20, 2023, approximately
78% of staff who work with incarcerated population have received a refresher
training on suicide prevention.
o Began developing a tracking system for self-injurious behavior: The Task
Force is actively working with the Office of Management Analysis and
Planning “OMAP” team to develop an application to track all incidents
involving self-injurious behaviors and to identify key trends.
o Planned routine assessments of suicidal gestures: The Task Force will review
suicide attempts via medication overdose and the use of ligatures (e.g., sheet,
shirt, pants, sweater, T-shirt, shoestring, or other clothing or bedding). The
Task Force is seeking to produce a heat map to identify facility spaces where
these events occur most often, which will enable the Department to conduct
targeted reviews to flag environmental risks for self-harm so they can be
remediated.
o Developed new refresher training curriculum: The Department created an
online learning course outline and video vignettes to update the “Crisis
Intervention and De-escalation” curriculum for all departmental staff.
o Evaluated suicide risk screening process for New Admissions: The Task Force
evaluated the suicide risk screening process for new admissions and found
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that every new admission receives a suicide risk screening by DOC using the
Suicide Prevention Screening form and also by H+H as part of its clinical
intake.
•

Among others, the Task Force plans to address the following priority issues:
o Review Policy and Procedures: DOC, H+H and the Department’s external
consultant will review the Suicide Prevention and Intervention Directive. This
review will serve as the basis for developing a joint policy and procedure for
screening, preventing, and responding to self-harming behaviors.
o Evaluate and review training: Review and update all DOC training previously
developed for suicide prevention and crisis intervention.
o Create consistent data with H+H: DOC reports it will be working with H+H
to develop common data points for tracking individuals on suicide
precautions.
o Improve follow-up for mental health referrals: DOC is evaluating how it can
ensure prompt clinic follow-up following a mental health referral.
o Improve Information Sharing During New Admissions Process: Ensure that
Court-ordered suicide precautions are flagged during New Admissions intake
and shared with the H+H Intake Medical Team and H+H Operations to be
addressed as part of their clinical assessments.
o Increase Video Surveillance Coverage: Consider installing additional
stationary cameras to support observation of those on enhanced suicide
precautions.
o Improved tracking for 15-minute tours: Investigate the use of automated or
technical operational controls to ensure 15-minute tours are conducted in all
Mental Observation units in every facility.
o Improved staffing for suicide watch: Rotate the officers assigned to Suicide
Watch Officer duty every 2 hours.

•

Addressing Barriers to Sharing information: The Law Department conducted an
analysis of the many laws, rules, and regulations governing the protection of health
information as it relates to sharing information between H+H and DOC. 69 The City
reported that the protection of health information is governed not only by HIPPA, but
that, in New York, the Public Health Law, the Mental Hygiene Law, the Correction Law
and regulations of the State Commission on Correction collectively establish a greater
degree of protection than HIPAA. The City further reports that DOC and H+H are in
agreement that DOC currently receives enough information from H+H to carry out its

This list includes 42 CFR § 2.15; 45 CFR §§ 160 and 164; Public Health Law §§ 18(6); Mental
Hygiene Law § 33.13(c)(10), (f); Correction Law § 601(a); (f); 9 NYCRR § 7064.8(15); 9 NYCRR §
7013.10 (c); and Correction Law § 601(f).
69

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responsibilities with respect to injuries, suicides, and other types of self-harming
behaviors. This will continue to receive close scrutiny from the Monitoring Team given
that the work to date suggests that barriers to information sharing do exist and impede the
ability or willingness to share information across and within agencies.
The Monitoring Team continues to engage with the Department on these efforts to ensure
all appropriate steps are taken to address the issues and poor practices previously identified. As
part of this work, the Monitoring Team will identify reasonable time frames for task completion
and will provide input and feedback as appropriate.
Looking Ahead & Next Steps
Deaths in custody remain a top priority given the rise in the mortality rate over the past
few years and the various common preventative measures that simply have not been in place for
too long. The Department has taken some important and concrete first steps and has crafted a
workplan and committed resources to improve practice in this area. In light of the Department’s
retention of a qualified expert in these matters and initial steps to address these issues, the
Monitoring Team has chosen not to retain a similarly-situated expert to do this work at this time.
The Monitoring Team will work closely with the Department to ensure that this work remains a
priority and remains on task to develop, implement, and sustain these critical prevention
measures.

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INTAKE
The Monitoring Team submitted a report to the Court on the status of the Department’s
compliance with the intake provisions of the Court’s orders 70 on February 3, 2023 (dkt. 504).
Intake is the processing center for people entering, exiting, and moving within the jails, and the
Department uses two types of intake units. First, individuals newly admitted to DOC custody
(“new admissions”) must be processed through intake before they are assigned to a housing unit.
Second, individuals may be brought to an intake unit within each individual jail either for the
purpose of exiting the facility (e.g., to go to Court, the hospital, or another facility) or to be
transferred within the facility (e.g., to the clinic following a use of force or to another housing
unit) (“inter/intra facility transfers”).
In the Monitoring Team’s February 3, 2023 report, the Monitoring Team found that the
Department has made tangible progress in its efforts to properly manage its intake units—uses of
force in intake units have decreased, the physical conditions of the units have improved, more
efficient procedures have been implemented to process people who are newly admitted to DOC
custody, and facility staff are relying on intake units less often following a use of force. The
chaotic environment and inefficient processes that first raised concerns for the Monitoring Team
appear to be waning. That said, some additional steps were needed to improve intake processing,
and the Department’s efforts since the February 2023 report are discussed below. 71 The

See First Remedial Order, ¶ A(3) (Revised De-Escalation Protocol) (dkt. 350), Second Remedial Order,
¶ 1(i)(c) (dkt. 398), Action Plan, § D, ¶ 2(b) and § E, ¶ (3)(a)-(b) (dkt. 465).
70

This update is also provided pursuant to the Court’s March 13, 2023 Order (dkt. 511) seeking a brief
update in the March 31, 2023 report detailing any developments that have occurred since the February 3,
2023 Special Report pertaining to Intake.
71

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Department’s efforts to reduce its reliance on the use of intake following a use of force incident
(First Remedial Order, ¶ A(3)) are discussed in the Compliance Assessment section of this
report.
The overarching goal of the provisions related to processing individuals in intake is to
ensure that people do not languish in intake units beyond a 24-hour period. Limiting the length
of stay in an intake unit is important because the physical plant of an intake unit (typically,
congregate pens with benches (no bunks) and shared toilets) means it is not a suitable housing
location. Intake units are intended to be processing hubs, and thus the efficiency of that
processing is the central concern. To that end, the Department’s quality assurance protocols to
support this goal are essential for good practice. Not only can quality assurance identify whether
broad goals, professional standards, or court-ordered requirements are being met consistently,
but it can also identify systemic problems and flaws in practice that obstruct an agency’s ability
to do so.
An update regarding the Department’s efforts to process people who are newly admitted
to the Department through intake within 24 hours is provided below, followed by an update on
the Department’s tracking processes for inter/intra facility transfers. The final section discusses
quality assurance and is applicable to both new admissions processing and inter/intra facility
transfers.
Intake for People Newly Admitted to the Department
The Monitoring Team’s February 2023 Report describes the procedures in place for
processing people who are newly admitted to the Department (see pgs. 15 to 18). These include
several notable components that should increase the efficiency of intake processing and the
accuracy of the data entered into the New Admission Dashboard. Since the Monitor’s last report,
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the Dashboard has been updated so that any “clock stoppages” (periods of time when the new
admission process is suspended, discussed in more detail below) are verified by the ADW on
duty, who now has an assigned office space in the intake unit. Most importantly, the efficiencies
created in intake processing address the primary goal of limiting the amount of time that
individuals spend in intake units before being transferred to an assigned housing unit. These
efficiencies include retraining and then consistently assigning staff, restructuring the division of
labor within intake, physical plant changes, transportation upgrades and improved interagency
collaboration. The new procedures implemented for time entries promote the development of
reliable data and should mitigate the possibility that data could be intentionally manipulated.
Consistently assigning specially trained staff in sufficient numbers to the intake area will help to
ensure that each staff member is aware of the required procedures and how to properly execute
and document them and is held accountable for any issues with the accuracy of the data. Also,
the division of labor between staff whose primary task is managing the individuals in intake and
those whose primary task is inputting data into the tracking database will help to ensure that both
tasks are prioritized and neither task is neglected. Thus far, the Monitoring Team has reported
only on intake processing at EMTC for males who are newly admitted to the Department. The
Department recently implemented a similar protocol at RMSC for newly admitted females,
which the Monitoring Team will review and discuss in future reports to the Court.
•

Length of Stay in Intake
The Monitoring Team analyzed new admissions processing data for January and

February 2023 (the first two months following the new procedures’ implementation) to
determine the proportion of people who were processed through new admission intake within the
24-hour timeline. Two different data points can be utilized as the “start time” when tracking

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length of stay: the time that an individual is transferred from NYPD to NYC DOC custody,
which typically occurs in a court setting (custody time) or the time that an individual arrives at
the intake unit (arrival time). Both are considered separately in the analysis below. 72 The “end
time” at which intake processing is considered complete is the time that the individual is either
transferred to a housing unit or discharged from custody (for those who make bail or are not
returned to custody following a return to court or trip to a hospital).
As shown in the section under the orange bar in the table below, whether using custody
time or arrival time as the starting point, nearly all individuals were processed within a 24-hour
period (95% using custody time, and 97% using arrival time) without deducting any clock
stoppages (discussed in more detail in the next section). In other words, the data presented in the
chart below is based on actual time between custody time/arrival time and processing end time,
without deductions for clock stoppages.
The area under the green bar in the table below shows the total length of stay for the
small proportion of individuals whose processing did not meet the 24-hour timeline (5% using
custody time, and 3% using arrival time). Of the small number of individuals who remained in
intake beyond 24 hours (n=136 using custody time and n=72 using arrival time), most were
housed within 30 hours.

As noted in the Monitor’s February 3, 2023 Special Report on Intake (dkt. 504), the Monitoring Team
assess the time each person arrives in the intake unit (i.e., “arrival time”) compared to the time the
individual is transported to their assigned housing unit when calculating whether the 24-hour requirement
has been met. Counsel for the Plaintiff Class have advised the Monitoring Team that it believes that the
assessment of compliance should be based on the time an individual is taken into custody (i.e., “custody
time”). Discussions about the appropriate compliance standard are ongoing. Given that, this report
provides outcomes using both data points for the Court’s consideration.
72

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Intake Processing Times for New Admissions Arriving at EMTC Intake
January 5 to February 28, 2023
Per Custody Time

Per Arrival Time

n=2,816

%

n=2,816

%

Housed/Discharged within 24 hours

2,680

95%

2,744

97%

Housed/Discharged beyond 24 hours

136

5%

72

3%

Outcome

Length of Stay (“LOS”) Beyond 24 Hours
LOS (# hrs. overdue)

n=136

%

n=72

%

24-27 hours (≤ 3 hrs.)

57

2.0%

31

1.1%

27-30 hours (3-6 hrs.)

28

1.0%

14

0.5%

30-33 hours (6-9 hrs.)

17

0.6%

9

0.3%

33-36 hours (9-12 hrs.)

7

0.2%

2

0.1%

36-48 hours (12-24 hrs.)

10

0.4%

10

0.4%

More than 48 hours (≥24 hrs.)

17

0.6%

6

0.2%

No patterns regarding overstays were detected among those who exited intake to a
housing unit versus those who were discharged from the Department. However, the Monitoring
Team found that a significant proportion of the individuals whose processing did not meet the
24-hour timeline had to return to court shortly after they arrived at the intake unit (discussed in
more detail below). The Department’s General Counsel has begun to consult leadership in the
Criminal Courts to identify potential changes to the appearance process for these individuals that
would allow them to be transferred to a proper housing unit, shower and change clothes before
having to present for another court appearance.
In summary, the data currently available indicate that the Department processed nearly all
people through new admissions intake at EMTC within 24 hours (by both custody and arrival
time) and that most of those who overstayed the 24-hour timeline were housed within 6 hours
thereafter.

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•

NCU’s Audits to Verify Data Entry
Concurrent with the implementation of the improved New Admission Dashboard, NCU

initiated an audit strategy to corroborate time entries using Genetec footage, as discussed in the
Monitoring Team’s February 2023 Report (see pgs. 20-22). Given its short tenure, the audit
process has been dynamic and continually refined. For instance, originally, NCU attempted to
conduct weekly audits but subsequently determined that this cadence was not useful to the task
of improving practice because the results of one weekly audit would be in the evaluation process
as the next audit began, thus impeding the development and implementation of any corrective
action plans or practice change. A bi-weekly cadence is currently being tested to ascertain
whether the flow of audit findings is conducive to practice improvements.
Audit results from January to and March 2023 are summarized for the 57 people who
were newly admitted 73 during the audits’ sampling frame.


54 of 57 people (95%) arrived in intake and were processed and transferred to a housing
unit within the 24-hour timeline (confirmed via Genetec review);



50 of 57 arrival time entries (88%) were generally accurate (i.e., within 20 minutes of
the time shown on Genetec). Among the seven inaccuracies, four incorrect entries were
for times before the person actually arrived, and three were for times after the person
actually arrived; and



46 of 57 housing time entries (81%) were generally accurate (i.e., within 20 minutes of
the time shown on Genetec). Among the eleven inaccuracies, seven incorrect entries

NCU confirms the status of all individuals in the intake to determine whether they are a new admission
or if the individual may already have been in custody and is therefore in intake as an inter/intra facility
transfer. Upon confirmation of the new admissions, the audit is limited to those individuals.

73

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were for times before the person was actually transferred to a housing unit, and four
were for times after the person was actually transferred to a housing unit.


6 of the 57 people (11%) had “clock stoppages” during the intake process. Of these,
three were housed within 24 hours of their arrival time in intake and three were not.

These audit results demonstrate that the Department still has work to do to ensure that
staff are accurately entering data regarding the person’s arrival time in intake and the time the
person was transferred to a housing unit. The Department reports that the staff involved were
counseled regarding their errors, which is a positive first step. The NCU staff’s time required to
complete these audits has also made it abundantly clear that an audit methodology relying on
retroactive confirmation via Genetec footage is likely the least effective (in terms of improving
practice) and most inefficient strategy for the task. NCU’s audit methodology is simply not
practical or, indeed, sustainable as a long-term strategy for ensuring data accuracy, though it
serves an important role as a temporary strategy until a more effective and practical quality
assurance process is put in place. Therefore, NCU’s methodology (a passable assessment of
small samples of cases) is reasonable only until other modes of quality assurance are fully
operational.
•

Temporarily Suspending New Admission Processing, a.k.a. Clock-Stoppage
Historically, the Department has identified circumstances in which new admission intake

processing is interrupted and has tolled its accounting of the processing time (i.e., “stopped the
clock”) until the circumstance is resolved and processing can resume, as discussed in the
Monitoring Team’s February 2023 Report (see pgs. 17 and 19-20). The situations in which the
Department temporarily suspends its intake processing clock include: when an individual is

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returned to court before the intake process is completed, an individual refuses to participate in
intake processing, an individual is transferred to a hospital or Urgi-Care (a clinic in another
facility on Rikers Island) before the intake process is complete, or an individual makes bail and
must be released from custody before the intake process is complete. Suspending the processing
of an individual through the intake process appears to have a logical element (e.g., processing
cannot occur if the person is not physically present) and may also be functional (e.g., Department
or CHS staff need to know that an individual will not be presented for a certain procedure).
Although the Department tracks all clock stoppages, data presented above regarding the 24-hour
timeline utilized a continuously running clock, without deducting any time when processing was
suspended.
Going forward, the Department would like to exclude these clock stoppages from the
calculations when determining compliance with the 24-hour requirement. The parameters and
appropriateness of this proposal requires discussion among the Parties and the Monitoring Team.
Because only two months’ data currently exists, decisions about how to proceed are premature.
That said, data from January and February 2023 provide some insight into this practice.
First, nearly all individuals (91%; 2,574 of 2,816) were processed through intake without any
suspension of the process. Further, the fact that the process was suspended in some cases did not
necessarily mean that the individual was not processed within 24 hours. In fact, among the 242
individuals whose intake process was suspended for some period of time, most were housed
within 24 hours (50% using custody time, 71% using arrival time). Among those whose intake
process was temporarily suspended and whose processing lasted more than 24 hours (n=120
using custody time, n=71 using arrival time), the largest category of suspensions occurred
because the individual was required to return to court (58% of those in intake longer than 24

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hours per custody time; 69% of those in intake longer than 24 hours per arrival time). The next
largest category of suspensions occurred because the individual refused to participate in the
intake process (21% of those in intake longer than 24 hours per custody time; 20% of those in
intake longer than 24 hours per arrival time). Suspensions for hospital transfer, Urgi-Care and
bail payment comprised much smaller proportions. 74
The Monitoring Team intends to provide the Parties with recommendations for
addressing the issue of clock stoppages once more data from at least a few more months becomes
available and has been evaluated.
Intake for those Transferred Within and Between Facilities
This section of the report discusses a different type of intake that does not relate to new
admission processing. Each facility has an intake unit that is used for a variety of purposes (e.g.
transporting individuals in/out of the facilities). As with new admissions, the Department is
required to process individuals through these intake units within 24 hours as the physical plant of
these units is not suitable for housing. While progress is evident in that the number of individuals
who remain in intake beyond 24 hours is decreasing, it does still occur. 75
In order to assess the amount of time individuals remain in intake, the Department must
track inter/intra facility transfers pursuant to ¶ 1(c) of the Second Remedial Order. To date, the
Department has not maintained valid system-wide intake length of stay data for inter/intra
facility transfers. The Monitoring Team has long encouraged the Department to address this

Note, these proportions do not total 100% because an individual’s intake processing may be suspended
more than once.

74

For instance, the Department recently reported a particularly egregious case to the Monitoring Team in
which an individual spent approximately 138 hours in intake over a 7- day period.

75

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issue, and in January 2023, a reasonable plan was developed. The Classification Manager, the
Staffing Manager, and members of their teams recently implemented this plan, which uses the
Department’s legacy Inmate Tracking System (“ITS”) and incarcerated individuals’
“accompanying card” or “Housing Locator Card” (which reliably establish the individual’s
identity) to track the times at which various events occur. 76 Further, specific staffing,
supervision, procedural and quality-assurance components were put in place, as described in the
February 3, 2023 report at pgs. 32 to 35.
ITS is a straightforward and intuitive data interface that requires minimal training in
order to utilize the system. When an individual arrives in or departs from an intake unit, staff
scan the unique bar code on an “accompanying card” or “Housing Locator card” and the
incarcerated individual’s profile appears on the computer. Intake staff must then select a reason
for the individual’s arrival or departure from a drop-down box. At this point, the individual’s
entry appears on the “Inmate Tracking Dashboard.” The staff responsible for scanning and
entering the intake data varies from facility to facility, but is typically the A station officer
assigned to the computer/desk in the intake unit.
Separate from ITS, the Inmate Tracking Dashboard lists all individuals in a facility’s
intake. At any time, staff may view the Inmate Tracking Dashboard to see who is in their intake
unit, the reason, the time they were scanned in and the time elapsed. The Dashboard also

The Department previously used RFID bracelets for this purpose but found them to be unreliable
because people in custody would sometimes destroy their bracelet or swap them with other individuals.
Utilizing the accompanying card, which remains in the Department’s possession at all times, should be
less susceptible to such problems.

76

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includes individuals who are expected to arrive in their intake from another area, such as court or
another facility.
The Captain assigned to the intake unit is responsible for the direct oversight of the
Dashboard. The on-duty Tour Commander is also required to review the Dashboard periodically
to ensure individuals are properly tracked in ITS and that no one remains in intake for a
protracted period. Facility Wardens have the ultimate responsibility to ensure compliance with
intake tracking and the timely processing of all individuals in their facilities’ intake units.
Recently, staff from the Deputy Commissioner of Facility Operations’ office began
reviewing Genetec Video, ITS and the Dashboard across all facilities. In the near future, a
protocol will be developed to reach out directly to facilities when any issues, discrepancies, or
intake overstays are identified. If the issue is not resolved by the facility, the staff from the
Operations Office will elevate the issue to the assigned Associate Commissioner. This quality
assurance monitoring was implemented only recently so the process and frequency have yet to be
finalized and remain subject to change.
The Department reported that the ITS tracking for inter/intra facility transfers would
occur by March 15, 2023. As of that date, the Department reported that ITS tracking was being
utilized at RNDC and RMSC, but not yet at the other facilities. On March 27, 2023, the
Department shared a memorandum with all facilities indicating that effective that date, facilities
were required to track individuals in intake using the Inmate Tracking System.
Following the March 27, 2023 rollout, the Monitoring Team conducted a site visit to
every facility’s intake to determine whether ITS and the Dashboard were being utilized. In every
intake visited, ITS was being utilized and nearly all individuals in the intake pens had been
entered into the system. The intake staff reported to the Monitoring Team that any individual
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who was not yet scanned into ITS arrived moments ago as the staff were attending to other
priorities that did not allow them to immediately scan the person into ITS. The reliability of ITS
data depends on intake staff’s diligence and organizational skill, which leads the Monitoring
Team to recommend that each facility develop clear procedures and appropriate working space
to ensure staff can accurately enter data into ITS, regardless of competing priorities. Overall, all
intake staff showed a clear understanding of the ITS, Dashboard, and transfer process. However,
efficient processing and accurate tracking data will depend on staff having access to appropriate
workspace and focusing on the task at hand, and also on the multiple levels of oversight to
identify and correct errors in order to elevate staff skill.
Quality Assurance of Department’s Tracking Efforts
The Second Remedial Order and the Action Plan require the Department to “implement a
reliable system to track and record the amount of time any incarcerated individual is held in
Intake and any instance when an individual remains in Intake for more than 24 hours.” 77 An
accurate tracking system is an important tool for identifying the extent to which this requirement
is met, but the mere presence of the tracking system does not connote compliance with the
requirement to expeditiously process incarcerated individuals within 24 hours. Similarly, a
quality assurance process to identify where problems may exist in intake processing, to ensure
the integrity of the data, and to assess whether strategies have successfully remediated problems
is also an important part of good practice. But it is important to note that these components
should not be so onerous that they detract from the primary goal of expeditiously processing

77

See Second Remedial Order, ¶ 1(i)(c) (dkt. 398), Action Plan, § E, ¶ (3)(a) (dkt. 465).

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individuals through intake. The efforts to create accurate tracking information and quality
assurance measures should play supporting roles.
Quality assurance strategies must be diversified—looking at different parts of an issue or
process—and must be capable of producing feedback expeditiously so that any needed practice
changes can occur swiftly. To date, the Monitoring Team has advised the Court about the
Department’s first quality assurance strategy developed for the purpose of supporting good
intake practice, namely NCU’s audits to verify time entries utilizing Genetec footage (also
discussed above regarding length of stay in intake). The focus during the past two months has
revolved around quality assurance efforts for new admission intake but this will also be relevant
to inter/intra transfers as this process comes online.
Given the concerns about the utility of NCU’s audit methodology discussed above, the
Monitoring Team has been contemplating and consulting with various actors in the Department
to determine whether more reasonable, operationally feasible quality assurance tools can be
devised. The Monitoring Team’s current thinking about a practical approach to promoting
efficient intake processing and minimizing data entry errors is summarized below:
•

On-the-Ground Oversight: The quickest and most effective way to ensure good practice
is to closely oversee the practice, provide guidance, and take corrective action
contemporaneously as necessary. Toward this end, oversight could be simultaneously
provided by: (1) consistently-assigned Captains who could supervise the work of intake
officers, verify the accuracy of data entry, trouble-shoot problems with individuals’
processing on a daily basis, and (2) staff from the Classification Manager’s office who
could routinely inspect the work of the intake staff, assess the efficiency of the intake
units’ various functions, and verify information entered into the tracking systems multiple
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times per week. The key strength of this type of contemporaneous oversight is the ability
to improve and/or correct staff practice as it occurs, thereby preventing problems from
becoming entrenched in practice. Staff from the Deputy Commissioner of Facility
Operations’ office have already begun this type of oversight of intra/inter facility
transfers.
Another important example of this type of close-in-time oversight is the
Department’s daily “New Admission Reports” that show the number of people who flow
through new admission intake each day, the minimum/maximum/average time of
processing and the number of people who remained in intake longer than 24 hours. The
report also shows the number and type of “clock stops.” Daily reports allow managers to
quickly scan a subset of data and inquire about any obvious anomalies (e.g., particularly
long or short processing times) close-in-time to the event to determine whether
processing problems or data entry errors are responsible for the anomalies.
•

Monthly Analysis of Intake Data: As discussed above, the Department implemented the
New Admission Dashboard to track the processing of all people newly admitted to the
jails. This system is capable of generating reports with individual level data, but the data
cannot analyze or interpret itself. The New Admission Report discussed above provides
daily aggregate data which provides an opportunity to quickly investigate the source of
individual anomalies—this is a useful tool. From there, good quality-assurance practice
requires an examination of aggregate data for longer periods of time, commonly monthly,
because daily reports will not show the emergence of trends over time. The Department
has conducted an initial assessment of aggregate data, but the Monitoring Team
encourages the Department to establish this analysis as a routine function with skilled

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staff that can conduct a more detailed analysis on a regular monthly cadence and provide
this information directly to the practitioners in the jails. This type of analysis is essential
for detecting anomalies, interpret key trends regarding length of stay, and directing the
effort for data-driven process improvements. For example, a scan of monthly data may
reveal intake stays of unusual duration (either very short or very long) that need to be
evaluated to ascertain whether the odd duration is related to an error in computation, a
legitimate delay in processing efficiency, or a delay in processing related to capacity or
workload, et cetera. The overall goal is to scrutinize the Dashboard data on a frequent
basis to identify anomalies and to utilize the data to identify areas where improved
practice is needed. The Monitoring Team has shared its own analytical approach with the
Department, which is working on a strategy to develop an internal capability for this type
of analysis.
Conclusion & Next Steps
The Department, finally, has made tangible progress in its efforts to properly manage its
intake units as outlined in this report and the February 3, 2023 report. The chaotic environment
and inefficient processes that first raised concerns for the Monitoring Team appear to be waning
from their height in the summer of 2021. That said, there is certainly more work to be done. As
this work continues, the Monitoring Team recommends that in the near term the following three
things occur:
•

Implementation of ITS to Track Intra/Inter-Facility Transfers: Support the roll-out
of ITS tracking and the Dashboard at all facilities to ensure they are incorporated into
practice.

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•

Appoint Dedicated Leadership of Intake Department-Wide: A specific leader of
Intake is needed to properly manage this issue. The leader must have the proper authority
and the necessary time to dedicate exclusively to managing the operational issues related
to intake. Intake units need to be monitored on a daily basis to ensure appropriate staffing
levels and to verify that staff are properly addressing their responsibilities for efficient
processing and accurate data entry. The leadership role will also require significant
problem solving abilities in order to address the multitude of issues that impact the
Department’s ability to process individuals in intake units within 24 hours. Given the
competing demands for facility leadership’s attention, a dedicated leader to support
Intake will ensure the issue receives the scrutiny required for compliance with the various
requirements. The Monitoring Team recommends the appointment of an Assistant
Commissioner of Operations or an individual of similar rank to exclusively manage the
intake units across the Department.

•

Improve Quality Assurance Process for New Admissions and Inter/Intra Facility
Intake Data. As explained in detail above, the Department must identify practical
strategies for ensuring efficient intake processing and accurate data entry in intake units.

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CLASSIFICATION OF INDIVIDUALS IN CUSTODY
The Department has been working to address several recommendations for managing and
housing those affiliated with gangs (security risk groups; “SRG”) and to repair its fragmented
classification process as required by the Second Remedial Order and the Action Plan. 78 As
discussed in the Monitor’s October 28, 2022 Report, the Department consulted with Dr. James
Austin, a nationally recognized expert on classification and safe housing of incarcerated persons,
on this work. The Deputy Commissioner of Classification, Custody Management and Facility
Operations, 79 hired by the Department in July 2022, serves as the Classification Manager and
oversees the centralized Custody Management Unit (“CMU”). 80 An ADW with appropriate
subject matter expertise oversees the day-to-day operation of the unit and supervises the CMU
staff dedicated to the classification and SRG blending functions. These individuals have regular
contact with staff assigned to the classification task in each facility as well as the security teams
who help to inform the SRG blending, as discussed in more detail below.
Classification Process
The CMU has several responsibilities, one of which is ensuring that people are housed in
units that are commensurate with their custody level. 81 Meeting this responsibility requires all

78

As required by the Second Remedial Order ¶ 1(f)(i) and Action Plan § E, ¶ 1 and 2.

79

As required by the Action Plan § A, ¶ 3(b)(ii)(2).

80

As required by the Action Plan § E, ¶ 1 and § E, ¶ 2.a.

A person’s custody level refers to their level of risk of institutional misconduct, which translates to the
level of security needed in their housing unit assignment to mitigate this risk. For example, someone who
is classified as “maximum custody” poses a high risk of institutional misconduct and should be housed in
a more secure setting than someone who is classified as “minimum custody” who poses a lower risk of
institutional conduct and therefore can be safely housed in a less secure setting.

81

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people to be properly classified upon admission (“initial classification”) and reclassified at the
60-day intervals required by policy (“reclassification”). 82 Once the classification instrument has
been completed, CMU must ensure that each individual is housed in a unit of the appropriate
type (i.e., dormitory housing for those classified as minimum custody, celled housing for those
classified as maximum custody) and must devise a mechanism to track whether the appropriate
housing assignment is maintained over time. 83 The Department is on a trajectory to meet each of
these responsibilities in short order.
As reported in the Monitor’s October 28, 2022 Report (see pgs. 90-91), the Department
took steps to clarify expectations, train staff, and reassign responsibilities to bring the necessary
integrity to the classification process. CMU staff are responsible for completing the initial
classification of a newly admitted person within 24 hours of the individual’s admission. Under
COVID-19 protocols, all new admissions are placed in quarantine housing for 10 days before
placement in a regular housing unit. Trained facility staff reclassify individuals at each facility at
60-day intervals. In October 2022, CMU created a set of weekly audit reports to monitor each
facility’s performance level regarding initial and reclassification functions and to take
appropriate steps to remedy any identified problems. This audit/performance enhancement
process appears to have been effective. In contrast to the large proportion of individuals with
outdated/incomplete reclassification identified by Dr. Austin in mid-2022, by early 2023, only a
very small number of people (less than 2%) had an overdue initial classification or
reclassification Department-wide. More specifically, of approximately 6,600 people in custody

82

As required by the Action Plan, § E, ¶ 2(a) and (b).

83

As required by the Action Plan, § E, ¶ 2(a) and (c).

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on any given day, an average of 51 individuals had incomplete initial classification and an
average of 45 individuals had incomplete reclassifications per week in January, and an average
of 37 individuals had incomplete initial classification and an average of 20 individuals had
incomplete reclassifications per week in February. 84 The Department’s efforts to reorganize
responsibilities, clarify expectations, train staff and conduct weekly audits appear to have
produced a system that produces timely initial classification and reclassification for people in
custody, as required by the Action Plan. Timely classification should lead to people being housed
in an appropriate housing unit, that is, higher-security units for those at higher risk of misconduct
and less restrictive units for those at low risk of institutional misconduct.
That said, the Department has identified a few threats to the validity of the system that
need to be corrected in order for the classification system to do its job, which is to accurately
categorize people according to their risk of institutional misconduct and then house them
appropriately. Echoing an issue discussed in previous Monitor’s Reports, 85 CMU identified that
some of the information captured by the classification process is not always accurate.
Classification forms involve a variety of risk factors. Some are related to a person’s current
charge and legal history, but the most powerful risk factors are those that are related to a person’s
behavior while in custody (i.e., the number of infractions they have accrued). The infraction
process, and its use as a risk factor, provides an incentivizing pathway for those who refrain from
assaultive conduct to be housed in a less-restrictive setting. The data must be accurate in order to

CMU also tracks a third type of classification, “Legal Reclassification,” which becomes necessary
when an individual’s legal status changes. These are not part of the Action Plan requirements and thus are
not discussed here.

84

85

See, for example, the Monitoring Team’s Eleventh Report, pgs. 319-320.

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produce a classification level that correctly categorizes people according to their risk of
misconduct and in order for the classification process to function as an incentive. In other words,
the classification level must accurately separate those who have been involved in assaultive
behavior from those who have not. CMU has identified problems with the reliability of
infractions (i.e., staff do not always issue an infraction when assaultive misconduct occurs),
which means the classification process will misidentify those individuals as lower risk on this
particular factor which in turn may result in their being inappropriately placed in a less restrictive
unit. CMU reports it is working to improve staff practice regarding issuing infractions for
assaultive behavior to ensure that the information used to derive a person’s classification level is
accurate.
Blending of Housing for Security Risk Groups
The Action Plan also requires the Department to eliminate the high concentrations of
people with the same SRG affiliation in the same housing units.86 CMU manages this function
by assigning people to specific housing units to ensure that no single unit has a high
concentration of people with the same SRG affiliation. This process requires daily oversight
from CMU and extensive coordination with the DW for Security and the security teams at each
facility. Previously, facilities functioned largely autonomously in this regard, but now, housing
unit assignments are made by CMU and the facility must notify CMU of all housing changes
using an Internal Change Form. ITS reports are used to identify when a person is “mishoused,”
meaning that their housing unit is misaligned with CMU’s original assignment. Further, each

86

As required by the Action Plan, § E, ¶ 2(d).

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facility’s blending is monitored using an SRG dashboard (a “heat map”) which has useful visual
cues when a housing unit has become imbalanced.
The Department began its SRG blending strategy at RNDC in February 2022, followed
by GRVC in summer 2022, and reports that all facilities except for AMKC are now appropriately
blended. The Monitoring Team reviewed weekly heat maps from February 2023 and found that
the mechanics of the system to rebalance units as individuals from a single SRG begin to
predominate appears to be functional.
In its effort to maintain proper housing according to classification/custody level and SRG
blend, CMU identified problems with “mishousing” (i.e., that people were sometimes not
assigned to a housing unit type commensurate with their custody level), which is an essential
precursor to having an appropriate SRG blend. [These housing assignments also have obvious
implications to the integrity of the classification system discussed above.] Problems arise when
facilities transfer individuals to new housing units without verifying appropriate placement with
CMU. CMU has a daily mishoused oversight process that identifies instances when an
individual’s housing unit is not commensurate with their custody level and/or throws off the
proper SRG blend. The number of people who are mishoused/improperly blended has decreased
since CMU placed renewed emphasis on the daily mishoused oversight process, but CMU has
indicated that oversight of mishousing and the facilities’ use of the Internal Change From
remains necessary to ensure the veracity of both the classification process and SRG blending
strategy.
Overall, the Department has implemented robust processes for ensuring timely initial
classification/reclassification and to decrease the concentration of people with the same SRG
affiliations in the same housing unit but has also identified various areas of practice that must be
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shored up to ensure the integrity of both functions. The Monitoring Team will continue to
consult with the Department to identify progress in the underlying procedures and to monitor
performance with regard to classification timeliness and proper housing assignments for people
in custody, as well as SRG blending.

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MANAGING INCARCERATED INDIVIDUALS FOLLOWING SERIOUS
INCIDENTS OF VIOLENCE
An essential component of safety for people and staff in correctional facilities is a
reliable, safe, and effective response to serious interpersonal violence. The Monitoring Team is
alarmed and troubled by the level of violence in the jails and has found that there is a compelling
need to control and extinguish gratuitous and predatory acts of serious violence committed by a
relatively small number of incarcerated individuals. The violence perpetuated by this small group
of individuals results in frightening levels of harm to other incarcerated individuals and staff.
The details of this violence are repugnant—examples include an individual with head to foot
injuries from a stabbing/slashing incident, an individual scalded with hot water, and an
individual so bloodied that a trail of blood was left across the floor of the housing unit following
a violent attack. This risk of harm is real and life threatening. The immediate need to control
individuals who engage in such violence is compelling and must be addressed by a restrictive
housing model that is designed to neutralize the behavior of those who choose to engage in
unbridled predatory violence. In particular, a restrictive housing model must effectively separate
those who have engaged in serious acts of violence from potential victims, provide the necessary
structure and supervision to provide safety to the individuals housed in the unit, and should
provide rehabilitative services that decrease the likelihood of subsequent violent acts.
The Department has long struggled to adequately manage this group of individuals and to
implement an appropriate restrictive housing model. For this reason the Action Plan (§ E, ¶ 4)
requires the Department to implement a restrictive housing program that will safely and
adequately manage those incarcerated individuals who have engaged in serious acts of violence
and therefore pose a heightened risk to the safety of other incarcerated individuals and staff.
Developing such a program requires consideration of a number of different factors. First, the
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program must comport with New York State law, Humane Alternatives to Long-Term Solitary
Confinement (“HALT”) and is subject to the approval of the Monitor. A number of other
considerations are also present. This includes the development and implementation of a program
model that avoids the many pitfalls the Department has experienced when implementing other
iterations of restrictive housing. Further, a significant number of local regulations and dynamics
must be considered. Additionally, the program must ensure that the various harmful practices
that are emblematic of solitary confinement are not replicated. A system can and must be
developed, but addressing the multitude of laws, regulations, issues and concerns (some of which
are conflicting) is challenging and finding a path forward must be done with care. Finally,
programming and services must be provided that reduce the risk of subsequent violence, which
requires collaboration among multiple divisions and agencies. All of this to say, the complexity
of the task cannot be overstated—programs for people with known propensities for serious
violence who are concentrated in a specific location have unique and essential security
requirements, particularly during time spent out-of-cell in congregate activities. This is why the
Department’s effort to develop an adequate program has languished for over 5 years and is still
not complete.
The Department has been working with Dr. James Austin, a nationally recognized expert
in the design and development of restricted housing programs, 87 and the Monitoring Team to
develop a program that meets the requirements of the Action Plan. An effective restrictive

Dr. Austin has designed and evaluated restrictive housing programs in many correctional systems
across the country, including the Federal Bureau of Prisons, the states of Ohio, Illinois, Mississippi,
Colorado, California, New Mexico, Kentucky, and the local California jails of Sacramento, Santa Clara,
and Alameda counties. The goal of Dr. Austin’s work has been to increase out-of-cell time, increase
access to rehabilitative programs, reduce the number of people assigned to restrictive housing, and reduce
the level of violence in these systems.

87

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housing model should: (1) limit placement to individuals whose violent behavior indicates that
they require such restrictions, (2) balance the need for heightened security and supervision given
the individuals’ demonstrated propensity for serious violence, while also providing appropriate
out-of-cell time, (3) provide a legitimate opportunity and incentive for individuals to participate
in rehabilitative programming designed to address the underlying causes of violent behavior, (4)
provide access to medical care, and (5) be vigilant about the risk of decompensation.
The Department’s existing restrictive housing model, ESH, has many of these
components including those that would meet the requirements of the Action Plan and reflect
sound correctional practice, but has long faltered in its implementation. More specifically, the
Department has not utilized a properly trained complement of staff, has been unable to ensure
access to required out-of-cell time, has been unable to control violence in the units, has not
provided dependable programming services, and has not provided transparent, objective criteria
for advancement and return to the general population. That said, certain components of the
Department’s legacy restrictive housing program’s design are not inherently problematic, and
therefore it is reasonable that Department is seeking to refine ESH versus developing an entirely
new model. The goal is to improve upon the program design (efforts to date have had a variety of
problems 88), while also attempting to safeguard against the implementation failures of the past.
Given the compelling need to have a program that provides sensible restrictions for those
with a known propensity for serious violence, the Department is currently pilot testing a refined
version of the ESH program. The proposed revisions to the ESH policy, reflected in the pilot,

See the Monitor’s June 30, 2022 Report where the design flaws of the RMAS program model are
outlined, along with concerns about the Department’s readiness for implementation.
88

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includes creating two levels of supervision, both of which permit 7 hours out-of-cell (this will
include a period of time for out-door recreation) and require the individual to engage in program
offerings during this time. In order to be placed in the unit, the individual must first be found
guilty of a certain set of infractions and a multi-disciplinary committee must then determine
placement is appropriate for the individual. The incarcerated individual may request a facilitator
at the adjudication hearing and is also present at the placement meeting with the ESH committee.
Fixed mechanical restraints (i.e., restraint desks) are utilized in Level 1 during congregate
programming time to ensure the safety of both peers and staff. When an individual in ESH
refrains from major misconduct and engages in programming as required, they are promoted
from Level 1 to Level 2, which does not utilize fixed mechanical restraints and includes
additional privileges (e.g., higher commissary spending limits). Safe access to programming in
congregate settings, as well as programming requirements that appropriately incentivize
engagement are important core components of this program.
The Monitoring Team supports the Department’s efforts to pilot the refined version of
ESH, but the Monitor has not approved this program. Approval has been withheld because the
program is still in the development stage, and requires further consideration, an assessment of the
effectiveness of certain components, and an evaluation of the quality of implementation to
determine whether additional revisions may be needed. Indeed, some components of the program
require considerable scrutiny, including the out-of-cell time (e.g., the amount permitted in Level
2, and the dependability of implementation for both levels), the use of fixed mechanical
restraints, the development of behavior support plans, the availability of programming, and the
work of the ESH Committee (to which Dr. Austin will provide technical assistance) and its
decision-making regarding placement and the transparency of program progression.

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Implementation of this program will require strong leadership and vigilant supervision, as well as
sufficient numbers of staff who have the necessary skills and a strong understanding of the
program’s goals, protections, and required procedures.
The refined ESH pilot is located at GRVC, 89 but the Department intends to utilize RMSC
for this program, and so construction is currently underway to provide improved housing unit
layout and functionality so that all program components can be properly implemented. The
RMSC facility will be split in order to maximize bed space for the general population
(incarcerated females) and to provide dedicated space for the restrictive housing program.
Specially trained staff will be assigned specifically to work in the restrictive housing units with
dedicated leadership.
Only with strong adherence to the protocols for ensuring appropriate placement, adequate
and durable safety protocols and legitimate opportunities for programming and advancement to
less restrictive settings will the Department succeed in providing a safe housing strategy to
manage those who have engaged in serious acts of violence. The Monitoring Team, in
collaboration with Dr. Austin, is working with the Department to develop an appropriate
monitoring strategy to assess the quality of implementation, including specific data that must be
tracked, and the impact on the level of safety in the jails. This, along with other input, will
support the assessment of the pilot to determine whether revisions or enhancements to the
program are necessary.

The overall conditions of GRVC are discussed in detail in the Security Practices & Indicators section of
this report.
89

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STAFF ACCOUNTABILITY
Investigations
Accountability for staff misconduct is a critical tool to address the patterns and practices
of excessive, unnecessary, and avoidable uses of force that continue unabated in this system.
Timely detection of misconduct and adequate and timely responses to those identified issues are
essential for the Department to successfully reduce its use of unnecessary and excessive force
and to encourage the safe and proportional use of force. The Monitoring Team’s analysis of
nearly all UOF incidents (via CODs, Rapid Reviews, and ID Investigations) continues to reveal
that misconduct is prevalent and there is no evidence to suggest that practices have materially
improved since the inception of the Consent Judgment. Effectively responding to the misuse of
force requires reliably identifying misconduct that occurs, and addressing that identified
misconduct throughout appropriate corrective action.
The Department has a reasonable framework for identifying misconduct through a
combination of Rapid Reviews 90, ad hoc review by Agency officials of use of force incidents,
Intake Investigations, and Full ID Investigations. The Department’s use of Rapid Reviews is
generally reasonable (although more work must be done to make the findings reliable
consistently) as discussed in the Compliance Assessment (First Remedial Order § A., ¶ 1)
section of this report.
While staff practice regarding use of force may not have appreciably improved to the
extent necessary for sustainable compliance, the Department’s ability to properly investigate use

Rapid Reviews are also referred to as “Use of Force Reviews” by the Department, but the moniker
Rapid Reviews will continue to be used in this report.

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of force incidents advanced significantly since the effective date of the Consent Judgment. All
use of force investigations are conducted through the Investigation Division (“ID”) via an Intake
Investigation conducted within 30 business days of an incident (with referrals, as necessary, for
further investigation). The Department’s investigators were conducting generally reliable
investigations, particularly within the Intake Squad (although there was still room for
improvement). Beginning in summer 2022, a discernable deterioration in the quality of
investigations conducted by ID was identified and there was evidence that ID was not
consistently addressing or analyzing the available evidence and their conclusions did not appear
to be objective. That is, beginning midway through 2022, a greater number of Intake
Investigations were being closed with no action, a significantly smaller number of cases were
being referred for further investigation via a Full ID Investigation, and misconduct was being
identified much less frequently than in the past. This deterioration in the quality of investigations
does not appear to be the result of less skilled investigators or supervisors nor does the
deterioration appear to be determined by the type of investigation (e.g., Intake Investigations
versus Full ID Investigations). The Monitoring Team observed a disturbing trend that suggested
under the new leadership of the Deputy Commissioner of ID, appointed in summer 2022, staff
had been influenced or prompted, either overtly or implicitly, to adopt a more lenient approach
when assessing cases and to change their practice in ways that compromised the quality of the
investigations.
The Department has recently taken some important steps to address these concerns. Most
importantly, a very recent change in ID’s leadership (at the end of March 2023), is expected to
mitigate any further decline in the quality of investigations and to restore the division’s previous

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progress towards achieving compliance. These issues are discussed in further detail in the
Compliance Assessment (Investigations) section of this report.
The rest of this section will depict the Department’s efforts to address those cases
identified as requiring informal or formal discipline, including addressing the backlog of
disciplinary cases and efforts to more efficiently process those cases that are referred for
discipline.
Discipline
The City and the Department have made significant strides in 2022 in addressing the
formal disciplinary process and reducing the backlog of discipline cases for use of force related
misconduct. The confluence of efforts to achieve compliance with the First Remedial Order,
Third Remedial Order, and the Action Plan have demonstrated that many of the convoluted and
dysfunctional components of the disciplinary system are in the process of being corrected. This
is significant as it will allow the Department to be in a position to apply more timely, reasonable
and reliable discipline. A summary of this work is outlined in this section. A more detailed
compliance assessment of the Department’s efforts to achieve compliance with relevant
provisions of the Consent Judgment and Remedial Orders is provided in the Compliance
Assessment section of this report.
The backlog of use of force cases pending with the Trials Division is the continuation of
the Department’s efforts to address a backlog of cases that originated in the Investigation
Division. The ID backlog began over 4 years ago. This situation is finally beginning to be
resolved as discipline for the misconduct identified by these backlogged investigations is being
imposed. As the Monitoring Team has reported for years, the backlog of investigations and the
subsequent backlog of disciplinary cases creates an untenable delay in accountability. This is

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why the Department could not continue with the status quo and had to make a concerted effort to
close the backlog cases as quickly as possible, while still imposing meaningful and proportional
discipline. It is for this reason that cases were not just summarily closed; instead, deadlines were
set to balance the need to address the backlog, and that provided sufficient time to close the cases
as meaningfully as possible. This approach ensured that proportional discipline was generally not
sacrificed for the sake of expediency, as that would undermine the larger objective of appropriate
discipline. Ultimately, the Trials Division struck that balance as it worked to close the backlog of
cases pending from December 31, 2020, and earlier. The same approach will be necessary to
address the remaining backlog (that is, cases pending more than a year from the date of the
incident), which is much smaller, but continues to drain the Trials Division’s ability to close
more recent cases in a timely manner.
The significant gains made in 2022 must certainly be acknowledged, but much more
work remains in order to achieve the ultimate goal of the reform effort, which is to impose timely
and meaningful discipline. For more recent cases, the Department still does not reliably or
consistently impose timely and meaningful discipline and so the same concerted efforts
demonstrated by the Department and the Trials Division in 2022 must continue. To that end, the
Monitoring Team provides recommendations at the end of this section on steps the Department
must take in order to continue its progress towards achieving Substantial Compliance with the
relevant disciplinary provisions of the Court’s Orders.
A summary of the current status of staff accountability is outlined below:
•

Case Closures: The Trials Division closed 2,163 use for force related disciplinary cases
in 2022, which is more than were closed in any other year of monitoring since the
effective date of the Consent Judgment and almost as many disciplinary cases closed in
than the previous 5 years combined (n= 2,225 cases were closed between 2017 to 2021).

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o Even with this accelerated rate of closure, the Monitoring Team has not identified
an overall negative impact on the appropriateness of the dispositions. The

Monitoring Team found that most of the discipline imposed (whether through
NPAs or OATH) was meaningful and proportional to the misconduct identified.
That said, the Monitoring Team found the use of lower-level sanctions (e.g., 10
days or less) and cases in which the disposition only remains on the staff’s
member’s record for one year for formal discipline must be reduced and
encourages prudent limitations on the use of this strategy going forward.
•

Pending Cases: As of the end of 2022, the number of pending cases continued to
decrease, to a total of 409 pending cases, with the vast majority of cases pending
occurring between January 1, 2021, and the present. This is the fewest number of pending
cases since June 2019 (n=407). The number of pending cases will, of course, often ebb
and flow. It is expected that more cases will be referred for discipline with the
improvements to the investigation division, but the Trials Division should be in a position
to better withstand an influx of new cases given the reduction in the backlog, improved
processes, and improved staffing.

•

Eliminating the Backlog: The Department has essentially eliminated the backlog of use
of force related disciplinary cases for incidents that occurred prior to December 31, 2020
(“the 2020 Backlog”). As of the end of February 2023, only 65 (6%) of the 1,110 cases
that were pending from this group in spring 2022 remained pending. 91 However,
eliminating the 2020 backlog does not mean that all cases are now closed timely. In
particular, a lag to close cases within one year from incidents occurring after December
31, 2020, continues to exist and must be addressed expeditiously. The Monitoring Team
provides recommendations regarding the closure of these cases pursuant to the Third
Remedial Order and the Action Plan at the end of this section. 92

The Department reports that the majority of cases that remain pending are with staff members on
excused leave (e.g. military or maternity leave). In some other cases, the Department is awaiting a
decision from OATH.

91

92

As required by the Action Plan, § F, ¶ 4.

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•

Staffing: The Trials Division has recruited and retained additional staff for the division
as required by the Action Plan. 93 That said, the City and Department must remain vigilant
in ensuring that the Trials Division maintains adequate staffing levels. Given that the
Trials Division is still not timely addressing disciplinary matters, additional staff are
necessary to meet the demands of the workload and must be brought on board as quickly
as possible.

•

Pre-Trial Conferences: OATH scheduled more pre-trial conferences in 2022 than ever
before (n=1900 compared with n=920 in 2021). 94 The availability of pre-trial conferences
has facilitated more timely resolution of matters because the ALJ can facilitate a
settlement (or schedule a trial) when the cases cannot be resolved between the
Department and the staff member directly.

•

Trials at OATH: Trials at OATH are occurring closer in time to the pre-trial conference
and are conducted more efficiently when they are convened. 95 The Report and
Recommendations from the ALJs are completed in a timelier fashion and generally
reflect an appropriate assessment and analysis of the Department’s disciplinary
guidelines. OATH has recommended termination for 12 staff for UOF related misconduct
in 2022, double the number recommended for this reason in 2021. This is particularly
noteworthy as OATH failed to recommend termination for any staff for UOF related
misconduct for the first 5 years of the Consent Judgment, despite circumstances that
merited such a recommendation.

•

Appeals: The increased amount of discipline imposed following a trial by OATH and
written Report & Recommendation by an ALJ has resulted in an increased number of
appeals to the Civil Service Commission. While the majority of appeals are affirmed, a
recent reversal of the Commissioner’s determination to terminate a staff member for
unnecessary and excessive force raises concerns about the City’s and Department’s

The requirements pursuant to Action Plan, § F, ¶ 1 are discussed in more detail in the Compliance
Assessment section of this report in conjunction with the compliance assessment for Consent Judgment, §
VIII., ¶ 4.
93

94

As required by the Action Plan § F, ¶ 10 (c)

95

As required by the Action Plan § F, ¶ 10 (d)

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ability to impose the requirements of the Consent Judgment. A motion for
reconsideration regarding this decision is pending.
•

Expedited Case Closures: Between mid-June and February 2023, a total of 31 cases
covering the conduct of 30 unique staff members, involved in 23 unique use of force
incidents, have been identified for expedited closure pursuant to § F., ¶ 2 of the Action
Plan. 25 of the 31 cases have been resolved with close-in-time discipline, which was
generally found to be reasonable. Of six cases that remain pending, two were just recently
identified for expedited closure, two are pending potential criminal prosecution, one was
Administratively Filed, and one case is now moot following the termination of the staff
member for another case. The specifics of these cases are discussed in the Compliance
Assessment (First Remedial Order § C, ¶ 2) section of this report.

•

Command Disciplines: The Department has implemented a revised Command
Discipline Policy to expand the use of Command Disciplines and provide a much-needed
path toward increased close-in-time discipline for lower-level use of force violations. 96
While the CD process is reasonable, the adjudication of CDs necessarily requires
appropriate management. The Department has long struggled to reliably and consistently
adjudicate CDs, and additional oversight and quality assurance is needed to ensure that
CDs are adjudicated as required by policy.

•

Addressing Unavailable Staff: The Department, including the Trials Division, has been
more vigilant than ever before in addressing staff unavailable to work by strengthening
procedures to ensure staff adhere to requirements regarding leave policies, identifying
staff for separation pursuant to local laws, utilizing suspensions, and bringing charges and
imposing more discipline than ever before. 97 This is described in more detail in the
Uniform Staffing Practices section of this report.

Looking Ahead
The Department has made a number of notable strides in its efforts to eliminate the use of
force disciplinary backlog and create a system that will support timely accountability. These

96

As required by the Action Plan § F, ¶ 3.

97

As required by the Action Plan, § F., ¶ 7.

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elements of progress were sorely needed in a system that for too long allowed disciplinary cases
to languish. The various strategies in place and rate of progress must continue with the same
level of focus and attention until timely, meaningful discipline is applied in all instances of
identified misconduct. To that end, the Monitoring Team makes the following recommendations
with respect to the Department’s efforts to achieve Substantial Compliance with the relevant
provisions of the Court’s orders:
•

Eliminating the Backlog of Cases Pending 1 Year or More From the Incident Date:
The Monitoring Team recommends that all pending use of force disciplinary cases that
occurred between January 1, 2021 and June 30, 2022 must be closed by July 14, 2023.

•

Evaluating the Use of Lower-Level Sanctions & Expungement: The Trials Division
uses of a range of sanctions, including a broad range of compensatory days from 1 to 60
days, to address the range of misconduct. This is necessary, as not all misconduct
requires the same level of sanction. In particular, some misconduct stemming from the ID
backlog warranted low-level sanctions. Further, in an attempt to expeditiously manage
cases, the Trials Division introduced an option for a disciplinary event to only remain on
the staff member’s record for one year 98 instead of five years, known as “expungement.”
Both of these strategies have been supported by the Monitoring Team as part of the
overall effort to efficiently process disciplinary cases, which was sorely needed given the
backlog. As the Department has made significant headway in clearing the backlog and
now that other avenues exist to address lower-level misconduct (e.g. the expansion of

The case will not be removed from the staff member’s file if during this one-year period, the staff
member is served with new charges on a Use of Force incident occurring after the date of signature on the
Negotiated Plea Agreement.
98

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Command Disciplines), the Trials Division must curtail its use of low-level sanctions and
expungement given that the cases referred to the Trials Division are generally now
reflecting mid-level to egregious misconduct and the sanctions must be proportional.
Accordingly, the Monitoring Team recommends that the Trials Division revise its
protocols, in consultation with the Monitoring Team, to limit the circumstances in which
low-level sanctions and expungement may be utilized, to be implemented no later than
July 14, 2023. This date should coincide with the elimination of the backlog.
•

Command Discipline: Expanded use of Command Disciplines necessitates vigilance by
the Department to ensure this process has integrity and is not abused. This includes
appropriate oversight of the revised Command Discipline process to ensure cases are
processed and not dismissed due to procedural errors. Further, oversight of the outcome
of CDs is necessary to ensure that they reach appropriate outcomes and do not simply
default to the lowest level sanction (despite evidence to the contrary). Appropriate
mechanisms must be in place to ensure that cases that require formal discipline are
referred. There must be sufficient oversight to ensure that if a staff member has exceeded
the number of allowable CDs in a given time period that the cases are referred for MOCs.
Finally, an appropriate tracking system for CD appeals must also be developed by the
Legal Division.

•

Staffing: The City and Department must continue to vigorously recruit necessary staff for
the Trials Division. While progress has been made, the number of staff is still not
sufficient to manage the caseload and process cases in a timely manner. As part of this
effort, the Monitoring Team also continues to strongly recommend that the City and
Department afford staffing in the Trials Division an opportunity to work remotely. Even

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if permitted for only a few days per week, this benefit would support the overall
recruitment efforts of qualified candidates.
A more detailed discussion of the Department and OATH’s efforts to achieve compliance
in the Fifteenth Monitoring Period (which covers July to December 2022) with the relevant
provisions of the Consent Judgment and Remedial Orders is outlined in the Compliance
Assessment section of the report.

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OVERARCHING INITIATIVES RELATED TO REFORMS
A number of overarching initiatives are necessary to support the reform efforts underway.
These include efforts to recruit various staff for the Department, efforts to manage the
requirements of the Consent Judgment, training staff on the many initiatives underway, the work
of the City’s Task force, and addressing the protracted length of stay among individuals in
custody. Each is taken in turn below.
Recruitment Efforts
The Department needs a strong recruitment and efficient hiring process to support the
reform effort given the need for additional support in many areas. Recruiting qualified candidates
to work in this Department is particularly challenging given its location in a residential area in
Queens (with its attendant transportation and parking issues), the disparaging public discourse
about the agency, and general constraints of City employment (including the lengthy onboarding
process, few options for remote work, residency requirements, etc.). Quite simply, recruiting
individuals to work at the Department of Correction is incredibly challenging. It is for these
reasons that creative recruitment efforts for positions with attractive benefits are needed to attract
qualified candidates.
Of greatest importance in the recruitment effort is for the Department to attract
individuals with correctional expertise from other jurisdictions to serve in leadership positions,
staff for the Trials Division, Investigations Division and Legal Division, as well as civilian staff
to backfill positions previously held by uniform staff. 99 The recruitment effort is supported by

99

As required by the Action Plan, § B ¶ 2.

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the HR Division in addition to a couple executive search firms to identify qualified candidates.
The HR Division has also advertised positions via job fairs and online marketing. Finally, the
Department, working with the Task Force, has also obtained a waiver of residency requirements
from DCAS for most new hires effective June 9, 2022. All of these should increase the pool of
candidates to fill the wide variety of positions that are critical to actualizing the vision for
reform.
The table below identifies the leadership positions that have been filled, the date of
appointment, and the departure date, if applicable.
Date of
Appointment

Title

Division

Chief of Staff

Commissioner’s Office

2/14/22

Assistant Commissioner

Programs

3/14/22

Associate Commissioner

Program & Community Partnership

3/14/22

Assistant Commissioner

Program Operations

3/18/22

Associate Commissioner

Human Resources

4/7/22

Assistant Commissioner

Advancement and Enrichment Program

4/7/22

Deputy Chief of Staff

Commissioner’s Office

4/11/22

Assistant Commissioner

Preparedness and Resilience

4/11/22

Deputy Commissioner

Management Analysis & Planning

4/18/22

Deputy Commissioner

Investigation Division

5/9/22

Deputy Commissioner

Security Operations

5/16/22

Deputy Commissioner

Trials

5/31/22

Assistant Commissioner

AIU

6/16/22

Assistant Commissioner

Human Resources

6/16/22

Deputy Commissioner

DCPI

7/1/22

Associate Commissioner

Data Quality & Metrics

7/3/22

Assistant Commissioner

CIB

7/11/22

Deputy Commissioner

Classification & Population
Management

7/25/22

Associate Commissioner

Trials

8/8/22

Deputy Commissioner/
General Counsel

Legal Division

8/8/22

Assistant Commissioner

Human Resources

8/8/22

111

Date of
Departure (if
applicable)

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Date of
Appointment

Date of
Departure (if
applicable)

Title

Division

Executive Director

Intergovernmental & Policy

8/8/22

Associate Commissioner

IT

8/8/22

Associate Commissioner

Operations

8/22/22

Assistant Commissioner

Data Analytics and Research

8/29/22

Deputy Commissioner

Administration

9/6/22

Assistant Commissioner

Training/Academy

9/6/22

Assistant Commissioner

Operations Research

9/12/22

Sr. Deputy Commissioner

Operations

10/31/22

Associate Commissioner

Operations

11/9/22

Deputy Commissioner

Training

12/5/22

Assistant Commissioner

Investigations

12/11/22

Assistant Commissioner

Investigations – PREA

12/19/22

Assistant Commissioner

Management Analysis and Planning

1/17/23

Assistant Commissioner

Training Academy

1/30/23

Deputy Commissioner

Health Affairs

1/30/23

Assistant Commissioner

Public Information

1/30/23

Assistant Commissioner

Security Operations

Pending Start
Date

Assistant Commissioner

Operations

Pending Start
Date

Assistant Commissioner

Operations

Pending OMB
Approval

Assistant Commissioner

Operations

Pending OMB
Approval

Assistant Commissioner

Operations

Pending Approval

Assistant Commissioner

Operations

Pending Approval

City Medical Director

Chief Surgeon, HMD

9/17/22
2/3/23

3/1/23

Pending OMB
Approval

Despite the many challenges to recruiting for positions within DOC, the Department has
successfully hired a number of qualified individuals as shown in the table above. As discussed
throughout this report, newly hired individuals with significant correctional expertise have
already positively impacted the jails’ operations. Broadening and deepening these improvements
demands even greater urgency in identifying candidates, especially critical leadership positions

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within the jails which are sorely needed given that the volume of work still required easily
exceeds the capacity of those currently on staff.
Department’s Engagement, Focus, and Collaboration Related to the Court’s Orders
Collectively, the Action Plan, Remedial Orders, and Consent Judgment include hundreds
of provisions, covering multiple facets of the jails’ operation and multiple divisions across the
agency. The number of provisions is only exceeded by their complexity, given that the problems
are interrelated and polycentric. Furthermore, multiple problems require the same set of
individuals to find solutions, and their attention cannot be dedicated to everything all at once.
Tasks must be appropriately synchronized, which requires a command of how issues are
interrelated and a clear sense of how things must be prioritized. Because implementation never
occurs without a glitch, properly managing the many Nunez initiatives also requires the ability to
pivot, re-prioritize and yet still ensure that all initiatives stay on track.
Although it increases the already high level of complexity, one benefit of the Action Plan
is that it has rallied multiple stakeholders to assist the agency and has catalyzed various
Department leaders to take ownership of protocols within their span of control. In an effort to
create a unified vision, in early 2023, the Commissioner convened a meeting with his executive
staff to outline the priorities to further advance the work under the Action Plan. The Deputy
Commissioner of Management, Analysis and Planning provides leadership and oversees the
project management support given to the leaders of key initiatives to ensure essential tasks are
enumerated, potential barriers are identified and addressed, and to ensure set timelines are both
ambitious and achievable. Further, teams dedicated to compliance with the Court’s orders within
the Legal Division and the Nunez Compliance Unit continue to competently manage many

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aspects of this work, including providing a considerable volume of information to the Monitoring
Team.
The fresh engagement of multiple stakeholders to address the requirements of the Action
Plan is a welcomed improvement to the initially narrow approach to the Consent Judgment that
did not attend sufficiently to the foundational issues which, left unaddressed, stymied progress in
achieving compliance. However, with this shift, the Department’s approach at times lacks a
through-line and is without an organizing thread for the robust efforts of multiple leaders in
various disciplines. This lack of a central organizing force means that at times, initiatives
continue forward even when a refocus to an adjacent issue is needed. Discussions with the
Monitoring Team to provide advanced notice of certain plans, to consult on certain initiatives in
progress, or to digest and respond to feedback also suffer from this lack of a unified vantage
point. Simultaneously, although the Department continues to provide all requested information,
the decrease in the number of individuals dedicated to facilitating the flow of information to the
Monitoring Team has led to delays in receiving requested information.
To facilitate continued progress toward the requirements of the Action Plan, Remedial
Orders and Consent Judgment, the Monitoring Team recommends that the Department:
1. Dedicate additional resources to supporting the work of the Monitoring Team to ensure
information is provided in a timely manner; and
2. Identify an individual to manage the Department’s overall compliance efforts with the
Court’s orders. An incredibly unique skill set is required. This individual must have
appropriate and recognized authority, a command of the Department’s entire operation,
and a nuanced understanding of the requirements in the various Court orders in this
matter. Their core tasks are to set priorities and resolve conflicts within those priorities

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that may demand the same resources; anticipate potential barriers to implementation;
communicate proactively with the Monitoring Team regarding upcoming initiatives,
progress and obstacles encountered; and respond to the Monitoring Team’s feedback and
ensure it is incorporated into practice.
Training Initiatives
A new Deputy Commissioner of Training was appointed in December 2022 (following
the appointment and very short tenure of an individual in September 2022). The new Deputy
Commissioner holds a doctorate in educational leadership, is well-qualified and also has
demonstrated skill, strong command of the issues, and has taken the pro-active initiative to be
transparent and collaborative with the Monitoring Team during his short tenure. Initiatives
undertaken by the Training Academy under his leadership include an entirely re-vamped
Captains’ Promotions program (which includes a shift to a two-week field training component), a
streamlined Recruit curriculum and handbook, improved Defensive Tactics training and manual
(which had been under development for some time), as well as a number of initiatives to meet
emergent needs such as training facility staff to use the New Admissions Dashboard and in
Suicide Prevention, improving processing of re-training requests, 100 and facilitating the use of
NYPD’s state-of-the-art Training Academy to house the January 2023 DOC recruit class. The
Monitoring Team has been invited to review and share feedback for new curricula, even those
that fall outside of the Nunez Consent Judgment’s training requirements. The Monitoring Team
looks forward to continuing to work with the Academy staff and its new leadership.

Through these efforts, the Department significantly reduced the re-training backlog and has been
providing re-training more timely.
100

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In 2022, the Department also began recruiting, training, and onboarding new correction
officers for the first time in three years, as depicted in the chart below:
Number of Correction Officers who
Graduated from Training Academy by
Graduation Year
Academy Class
Graduation Date
Total
2009

212

2010

0

2011

398

2012

863

2013

645

2014

485

2015

1,099

2016

1,329

2017

2,044

2018

1,213

2019

382

2020

0

2021

0

2022

230

2023

97*

*Current Academy Class, not yet graduated.

City-Wide Support of Reform Efforts
The City reports that the Rikers Island Interagency Task Force (“City Task Force”),
comprised of representatives from key City agencies, continues to meet weekly to address issues
related to the reform effort and to ensure they are supporting the work by eliminating obstacles to
implementation. The City reports that the City Task Force has addressed the following issues
since October 2022: Body scanners and drug-sniffing dogs for staff, adjusting college credit
requirements for new officers, Fentanyl/harm reduction in housing units, evaluating need for
continued use of the Emergency Executive Order, addressing construction needs, and addressing
funding and vetting timelines for new hires.

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The Monitoring Team continues to recommend certain issues to the City Task Force. In
particular, the Monitoring Team encourages the City strengthen recruiting efforts by offering
remote work options in order to better recruit certain positions, in particular, for the Trials and
Legal Division staff. Unfortunately, the City reports that any potential remote work option is
currently limited to those covered by the City’s agreement with DC37 union, where a pilot is to
be developed by June 2023. It is the Monitoring Team’s understanding that the staff in the Trials
Division and Legal Division are not a part of this union and thus are not eligible for participation
in this pilot program. The Monitoring Team continues to strongly encourage the Department to
develop a remote work option, even for a few days per week, for staff with amenable job
responsibilities as it would greatly enhance the Department’s ability to attract qualified
candidates.
Reducing the Population & Addressing Increasing Lengths of Stay in Custody
The type and number of individuals in DOC’s custody has evolved over the course of the
Consent Judgment. The vast majority of individuals incarcerated at Rikers Island are held pretrial (a small proportion of individuals in custody are sentenced to a year or less). For many
years, New York City has engaged in an exceptional effort to reduce its incarcerated population.
Since the Consent Judgment went into effect in 2016, the average daily population has decreased
40% (n=9,802 in 2016 compared with n=5,913 in 2023). However, the jails’ lowest population
was achieved during the initial stages of the COVID pandemic (in May 2020, the average daily
population was 3,927) and has since increased. As a result of bail reforms, the characteristics of
those who are incarcerated have become increasingly serious and complex. As of March 2023,
almost 70% of individuals in the Department’s custody have a violent felony as their most
serious current offense, compared to about 40% in August of 2017. Further, the proportion of

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people in custody with mental health challenges has increased as well. There is no question that
any personal challenges an individual may have faced prior to incarceration are only exacerbated
by exposure to a correctional environment. This change in population also changes the dynamics
of the nature of the work of the Department’s staff as well, requiring greater mastery of crisis
intervention and skills to resolve interpersonal conflict.
Reducing the overall jail population is necessary to support the overall reform efforts and,
in particular, because it would reduce the number of people exposed to the dangerous conditions
in the facilities. Given the imminent risk of harm to those incarcerated in New York City’s jails,
all stakeholders must continue to maximize every possible avenue to reduce the population, by
reducing the number of people sent to jail, expeditiously processing court cases, or via release to
the community. 101
Unfortunately, efforts to reduce the number of people in custody have been undercut by
the number of people with extraordinarily long lengths of stay who are languishing in the
Department’s custody, as discussed in the Monitor’s October 28, 2022 Report (at pgs. 4-5).
Nationally, the average length of stay (“ALOS”) among people in pre-trial custody is
approximately 30 days. The Department’s ALOS is significantly longer which contributes not
only to the size of the population in the jails, but also to the stress and frustration experienced by
people in custody and presents challenges for providing rehabilitative programming in a setting
designed to address the short-term needs of people pending trial. Given the current level of

New York State Correction Law 6-a affords the City the power to release incarcerated individuals,
who have been sentenced to under one year behind bars, into a work release program. Since 2020, the
City has released 327 incarcerated individuals to work release programs (297 in 2020, 13 in 2021, and 62
in 2022). As of March 28, 2023, there are approximately 460 incarcerated individuals with a sentence of a
year or less in the Department’s custody.

101

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violence in the jails, longer lengths of stay also mean that these individuals are at risk of harm for
longer periods of time. Conversely, these dynamics can also compound to produce high levels of
violence among some who are languishing in the jails and contribute to concerns about safety for
both people in custody and staff. For all these reasons, the work of reforming the jail system
would benefit from long-term efforts to shorten the length of stay among people in custody
whenever possible, and in the short-term, from expediting the cases of those who have been in
custody for particularly long periods of time.
Historical length of stay data can be understood in two ways. First, the chart below shows
the average length of stay across all people in custody since 2016. Between 2016 and 2022, the
ALOS increased 89%, from 61.1 days to 115.3 days. The ALOS in 2022 was nearly four times
the national average.

Average Length of Stay, 2016-2022
140
120
100
80
60
40
20
0

61.1

63.4

2016

2017

73.3

2018

82.3

89.6

2019

2020

104.5

2021

115.3

2022

ALOS in Days

Second, as shown in the table below, the number of people who have been in custody for
more than one year has increased as a proportion of the total population. This proportion
increased significantly with the onset of the COVID pandemic when the number of people in
custody decreased but court processing slowed, and cases began to take longer to be processed.

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Proportion of People In Custody for More than One Year, 2016-2022
2016

2017

2018

2019

2020

2021

2022

# > 1 year

1,335

1,213

1,218

971

1,360

1,666

1,382

ADP

9,454

8,944

7,960

6,341

4,855

5,258

5,816

% >1
year

14%

14%

15%

15%

28%

32%

24%

Note: Number of people in custody for more than one year is as of the end of each calendar year.
ADP is the average daily population in December of each calendar year.

The City reports that the Mayor’s Office of Criminal Justice (“MOCJ”) has taken the
following steps to reduce the lengths of stay in the jails:
Coordination with District Attorneys in Each Borough
•

List of Individuals in Custody More than One Year. At regular intervals, MOCJ
compiles a list of “long stayers” that includes the individual’s name, length of stay,
pending charges, along with other information. 102 People with charges in multiple
boroughs are also identified. In October 2022, MOCJ sent initial borough-specific lists to
each District Attorney’s office and routine updates have continued to be shared.

•

Regular Meetings with/Updates from District Attorneys to Prioritize and Expedite
Cases. In January 2023, MOCJ convened a meeting with DAs from all boroughs to
discuss a process for collaborating with defense counsel and the courts to expedite cases.
Every few weeks, each borough updates MOCJ on the status of each case that was
prioritized for expedited processing.

Coordination with Other Stakeholders

102

•

Coordinating with the Center for Justice Innovation (“CJI”). Since October 2022,
MOCJ has worked with the CJI (formerly the Center for Court Innovation, or CCI) to
identify any overlap in target populations. Specifically, MOCJ’s focus on long lengths of
stay intersects with some of CJI’s projects involving specialty courts as well as CJI’s
Population Review project.

•

Coordinating with the Office of Court Administration (“OCA”). OCA reports it has
launched its own initiative to expedite cases of people who have been in custody for two
years or more. MOCJ has provided OCA with its list of individuals in custody for more
than one year, along with other information, in order to coordinate efforts.

As required by the Action Plan § B, ¶ 4.

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These steps appear to be useful to the overarching effort to expedite cases for individuals
with long lengths of stays in the jails. Between June 14, 2022 and February 23, 2023, the City
reports that a total of 584 cases involving people with lengths of stay longer than one year were
processed. In 4% of these cases, the defendant was found guilty at trial; in 81%, the defendant
pled guilty; in <1%, the defendant was acquitted at trial; in 12%, the case was dismissed; and 3%
had other dispositions. However, more work remains to be done.
The Monitoring Team recognizes that reducing length of stay is only one component of
broader reforms to reduce the number of people in custody, and as noted above, other initiatives
must complement this work. Court processing is a complex endeavor involving many actors
beyond the Department, which can sometimes lead to a diffusion of responsibility such that no
one agency takes responsibility for the outcome. An individual’s length of stay in jail is the
product of actions by a variety of stakeholders—the courts, prosecutors, and defense counsel.
With so many agencies and individual actors involved, all too often, the responsibility for
addressing delays and other structural problems becomes diffuse and uncoordinated. It is
imperative for these stakeholders to collaborate to quickly and creatively find ways to process
cases more expeditiously through the court system and to otherwise limit the use of secure
detention (e.g., via joint action review committees, jail diversion programs, etc.). This group of
stakeholders collaborated effectively at the onset of COVID-19 to significantly reduce the jails’
populations, so such actions are clearly possible. A comparable level of haste is required to limit
exposure to and relieve pressure on the jails.

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15TH MONITORING PERIOD COMPLIANCE ASSESSMENT FOR SELECT
PROVISIONS OF THE CONSENT JUDGMENT AND FIRST REMEDIAL
ORDER
This section of the report assesses compliance with a select group of provisions from the
Consent Judgment and First Remedial Order as required in the Action Plan § G: Assessment of
Compliance & Reporting in 2022, ¶ 5(b). This compliance assessment is for the period covering
July 1, 2022 to December 31, 2022 (“Fifteenth Monitoring Period”). 103 The following standards
were applied: (a) Substantial Compliance, 104 (b) Partial Compliance, 105 and (c) NonCompliance. 106 It is worth noting that “Non-Compliance with mere technicalities, or temporary
failure to comply during a period of otherwise sustained compliance, will not constitute failure to
maintain Substantial Compliance. At the same time, temporary compliance during a period of
sustained Non-Compliance shall not constitute Substantial Compliance.” 107

The Monitoring Team did not assess compliance with any provisions of the Consent Judgment or
Remedial Orders for the period between July 1, 2021 and December 31, 2021 (the “Thirteenth Monitoring
Period”). The Court suspended the Monitoring Team’s compliance assessment during the Thirteenth
Monitoring Period because the conditions in the jails during that time were detailed to the Court in seven
status reports (filed between August and December 2021), a Remedial Order Report (filed on December
22, 2022) as well as in the Special Report filed on March 16, 2022 (dkt. 441). The basis for the
suspension of compliance ratings was also outlined in pgs. 73 to 74 of the March 16, 2022 Special Report
(dkt. 438).
103

“Substantial Compliance” is defined in the Consent Judgment to mean that the Department has
achieved a level of compliance that does not deviate significantly from the terms of the relevant
provision. See § XX (Monitoring), ¶ 18, fn. 2. If the Monitoring Team determined that the Department is
in Substantial Compliance with a provision, it should be presumed that the Department must maintain its
current practices to maintain Substantial Compliance going forward.
104

“Partial Compliance” is defined in the Consent Judgment to mean that the Department has achieved
compliance on some components of the relevant provision of the Consent Judgment, but significant work
remains. See § XX (Monitoring), ¶ 18, fn. 3.

105

“Non-Compliance” is defined in the Consent Judgment to mean that the Department has not met most
or all of the components of the relevant provision of the Consent Judgment. See § XX (Monitoring), ¶ 18,
fn. 4.
106

107

§ XX (Monitoring), ¶ 18.

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The Monitoring Team’s assessment of compliance for all other provisions of the Consent
Judgment (required by § XX, ¶ 18 of the Consent Judgment) and the First Remedial Order that
are not outlined below are suspended for the time period covering January 1, 2022 to December
31, 2022. While compliance assessments for these provisions are not included in this report, the
Monitoring Team continues to collect and analyze relevant information regarding the
Department’s obligations under the Consent Judgment and the Remedial Orders on a routine
basis. The current conditions suggest that the Department’s compliance with these provisions of
the Consent Judgment and First Remedial Order, at best, have remained the same and in some
cases may have gotten worse.

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•

INITIATIVES TO ENHANCE SAFE CUSTODY MANAGEMENT, IMPROVE STAFF SUPERVISION,
AND REDUCE UNNECESSARY USE OF FORCE (REMEDIAL ORDER § A)

REMEDIAL ORDER § A., ¶ 1 (USE OF FORCE REVIEWS)
§ A., ¶ 1. Use of Force Reviews. Each Facility Warden (or designated Deputy Warden) shall promptly review all Use of
Force Incidents occurring in the Facility to conduct an initial assessment of the incident and to determine whether any
corrective action may be merited (“Use of Force Review”). The Department shall implement appropriate corrective action
when the Facility Warden (or designated Deputy Warden) determines that corrective action is merited.
i. The Department, in consultation with the Monitor, shall implement a process whereby the Use of Force Reviews
are timely assessed by the Department’s leadership in order to determine whether they are unbiased, reasonable, and
adequate.
ii. If a Facility Warden (or Deputy Warden) is found to have conducted a biased, unreasonable, or inadequate Use of
Force Review, they shall be subject to either appropriate instruction or counseling, or the Department shall seek to
impose appropriate discipline.

This provision requires facility leadership to conduct a close-in-time review of all use of force
incidents (“Rapid Reviews” or “Use of Force Reviews”). Further, this provision requires the
Department to routinely assess Rapid Reviews to identify any completed reviews that may be biased,
unreasonable, or inadequate and address with appropriate corrective action.
Use of Force Reviews – Assessments of Incidents
During this Monitoring Period, Rapid Reviews assessed 3,183 (98%) of the actual uses of force.
The chart below shows the Rapid Review findings from January 2018 to December 2022 (covering the
past ten Monitoring Periods).

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Rapid Review Outcomes, 2018 to December 2022
2018

2019

2020

2021

2022

Jan-June
2022

July-Dec.
2022

Incidents Identified as Avoidable, Unnecessary, or with Procedural Violations
Number of
Rapid Reviews

4,257
(95% of
all
UOF)

6,899
(97% of
all UOF)

6,067
(98% of all
UOF)

7,972
(98% of all
UOF)

6,889
(98% of all
UOF)

3,183
(98% of all
UOF)

3,706
(98% of all
UOF)

Avoidable

965
(23%)

815
(12%)

799
(13%)

1,733
(22%)

1,135
(16%)

549
(17%)

586
(16%)

345 (11%)
(JulyDecember
2020 Only)

1,233
(16%)

835
(12%)

515
(16%)

320
(9%)

1,835
(30%)

3,829
(48%)

3,296
(48%)

1,686
(53%)

1,610
(43%)

1,748

1,323

Violation of UOF
or Chemical
Agent Policy
Procedural
Violations 108

1,644
(39%)

1,666
(24%)

Corrective Action Imposed by Staff Member
Number of Staff
with
Recommended
Corrective Action

3,595

3,969

2,966

5,748

3,071

The data above reveals that in 43% of the incidents that occurred during the current Monitoring
Period, that facility leadership identified that staff made procedural errors (e.g., failure to secure doors,
failure to apply restraints properly), some of which directly contributed to the circumstances that
facilitated the incident. This, in addition to the 17% of incidents that were determined to be
“avoidable” demonstrates that even the Department’s internal analysis (which still requires refinement)
shows that staff are not applying the requisite skill set and decision-making needed to decrease the use
of force rate. There is much work to do in this area.
Quality of Use of Force Review Assessments
Rapid Reviews identify procedural violations, recommend corrective action for staff
misconduct, and also identify incidents that are avoidable. These findings are relied upon by both the
Department and Monitoring Team to identify patterns and trends. That said, Rapid Reviews do not
always reliably and consistently identify all issues that would reasonably be expected to be identified
through a close-in-time assessment of the incident videos.

Procedural errors include a variety of instances in which staff fail to comply with applicable rules or
policies generally relating to operational functions, such as failure to don equipment properly (such as
utilizing personal protective equipment), failure to secure cell doors, control rooms, or “bubbles,” and/or
the failure to apply restraints correctly.
108

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Beginning in May 2022, the Deputy Commissioner of Security Operations (also the Security
Operations Managers as required by Action Plan § D., ¶ 1) has taken steps to improve the reliability of
the Rapid Reviews by overseeing the Rapid Review process. Since then, the Monitoring Team has
noted improvement in leadership’s ability to identify and address violations, specifically those related
to factors that contributed to an incident (e.g. unsecured cell doors; off-post staff). The Security
Operations Manager holds routine meetings with facility leadership who conduct the Rapid Reviews,
and one-on-one meetings with ESU leadership to work through the Rapid Reviews involving ESU
staff. The Security Operations Manager often addresses specific themes of operational failures with
those who conduct the Rapid Reviews to encourage greater vigilance, which appears to be bearing
fruit.
That said, some Rapid Reviews are patently biased, unreasonable, or inadequate. The Security
Operations Manager has taken steps to address these failures through informal counseling of staff who
conduct Rapid Reviews. In one particular case, the Security Manager recommended formal charges for
an individual who conducted an egregiously inadequate Rapid Review.
Recommended Corrective Action
In response to identified problems with staff practice, Rapid Reviews can recommend various
types of corrective action, including counseling (either 5003 or corrective interviews), re-training,
suspension, referral to Early Intervention, Support and Supervision Unit (“E.I.S.S.”), Correction
Assistance Responses for Employees 109 (“C.A.R.E.”), Command Discipline (“CD,” as further
discussed in the Compliance Assessment (Staff Accountability & Discipline) section of this report, and
a Memorandum of Complaint (“MOC”). The Monitoring Team has found that corrective actions are
generally imposed when recommended and NCU also collects proof of practice to demonstrate that
corrective actions have occurred.
The most frequent corrective action recommended is a Command Discipline. In fact, the
recommendation for a Command Discipline increased during this Monitoring Period compared to the
last (1,216 compared with 902 respectively, an increase of 35%). Rapid Reviews referred staff for retraining more often during this Monitoring Period compared to the last (171 compared with 99
respectively, an increase of 73%). At the same time, significantly fewer 5003 counseling and corrective

C.A.R.E. serves as the Department’s Wellness and Employment Assistance Program. C.A.R.E.
employs two social workers and two psychologists as well as a chaplain and peer counselors who provide
peer support to staff. The services of C.A.R.E. are available to all employees of the Department. The
Department reports that the members of the unit are tasked with responding to and supporting staff
generally in the day-to-day aspects of their work life as well as when unexpected situations including
injuries or serious emergencies occur. C.A.R.E. also works with staff to address morale, productivity, and
stress management, and provide support to staff experiencing a range of personal or family issues (e.g.
domestic violence, anxiety, family crisis, PTSD), job-related stressors, terminal illness, financial
difficulties, and substance abuse issues. The C.A.R.E. Unit also regularly provides referrals to community
resources as an additional source of support for employees. Staff may be referred to the C.A.R.E. use by a
colleague or supervisor or may independently seek assistance support from the unit.
109

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interviews were recommended via Rapid Reviews compared to the previous Monitoring Period (1,004
versus 1,935, a decrease of 48%). The Monitoring Team has not determined the reason for this decline
but will continue to evaluate the situation.
Conclusion
While the Rapid Reviews do identify a significant volume of problems with staff practice, they
do not reliably identify all issues. Further, to date, they have not proven to be an effective tool for
preventing similar misconduct from re-occurring. Rapid Reviews identify and recommend corrective
action for a wide array of security lapses, yet the same problems persist Monitoring Period after
Monitoring Period. There is no question that utilizing Rapid Reviews is grounded in sound correctional
practice and is an appropriate tool. However, the use of Rapid Reviews to catalyze improved practice
will likely only occur when facility leadership, especially the direct supervisors of Correction Officers,
gain a stronger command of the security protocols and procedures that must be utilized on a daily
basis, develop skills to guide and coach their staff toward sound correctional practice, and are actively
engaged in supervising staff in a manner that allows them to address these issues in real time. That
said, Rapid Reviews continue to be valuable tool and the improvements in identification of issues in
this Monitoring Period is encouraging.
COMPLIANCE RATING § A., ¶ 1. Partial Compliance

REMEDIAL ORDER § A., ¶ 2 (FACILITY LEADERSHIP RESPONSIBILITIES)
§ A., ¶ 2. Each Facility Warden (or designated Deputy Warden) shall routinely analyze the Use of Force Reviews, the
Department leadership’s assessments of the Use of Force Reviews referenced in Paragraph A.1(i) above, and other
available data and information relating to Use of Force Incidents occurring in the Facility in order to determine whether
there are any operational changes or corrective action plans that should be implemented at the Facility to reduce the use of
excessive or unnecessary force, the frequency of Use of Force Incidents, or the severity of injuries or other harm to
Incarcerated Individuals or Staff resulting from Use of Force Incidents. Each Facility Warden shall confer on a routine basis
with the Department’s leadership to discuss any planned operational changes or corrective action plans, as well as the
impact of any operational changes or corrective action plans previously implemented. The results of these meetings, as well
as the operational changes or corrective action plans discussed or implemented by the Facility Warden (or designated
Deputy Warden), shall be documented.

The goal of this provision is to ensure that the leadership of each facility is consistently and
reliably identifying operational deficiencies, poor security practices, and problematic uses of force and
that they address these issues so that supervisors and staff alike receive the guidance and advice
necessary to improve their practices. Facility leadership is required to routinely analyze available data
and information regarding uses of force, including the daily Rapid Reviews, to determine whether any
operational changes or corrective action plans may be needed to reduce the use of excessive or
unnecessary force, the frequency of use of force incidents, or the severity of injuries or other harm to
incarcerated individuals or staff resulting from use of force incidents.
As discussed throughout this report, the current on-going harm to people in custody and staff
cannot be overstated, and the factors contributing to the Department’s inability to properly infuse an

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appropriate skillset to minimize this risk of harm has been discussed in each of the Monitoring Team’s
reports to date. It is for this reason that the Monitoring Team recommended that the Department
broaden the criteria of candidates who may serve as facility Wardens, to allow for the selection of
individuals based on their breadth of experience and demonstrated effectiveness as leaders. 110 Having
more skilled facility leaders should create new potential for developing the skill set of their
subordinates, and thus it is an essential starting point for the culture change required.
To support facility leadership’s ability to do so, Action Plan § A., ¶ 3(b) requires a new agency
leadership structure which, through the oversight and guidance of Deputy Commissioners and
Associate Commissioners, should help to develop the quality of facility leaders so they can meet the
expectations above. Further, in December 2022, the Court issued an order that permitted the
Department to expand the pool of candidates that may be considered to serve as Facility Wardens
given the current compliment of staff available to serve in the role was not sufficient and the
Department’s attempts to develop alternative leadership structures in the command were not workable.
New Agency Leadership Structure
Throughout 2022, the Commissioner brought in a new executive leadership team to direct the
agency’s efforts regarding security, staffing, classification and operations and to work alongside
facility leadership. This action was strongly supported by the Monitoring Team and was a necessary
first step toward meeting the requirements of this provision. The three well-qualified Deputy
Commissioners of Staffing, Security, and Classification/Operations and two Associate Commissioners
of Operations have made notable progress in identifying problems and making plans to address them
and have already demonstrated a positive impact on the jails’ operations. The essential next step for
ensuring that facility leaders are capable of meeting their responsibility under this provision is to
address the skill and leadership deficits among existing Wardens.
Facility Leadership
The Department’s leadership (both uniform and civilian) routinely meet to discuss the various
issues facing the agency, and facility leadership consistently conducts Rapid Reviews for every use of
force incident (see the Compliance Assessment (First Remedial Order ¶ 1) section of this report).
However, to date, facility leaders have simply been unable to abate the persistent issues contributing to
the risk of harm, including the use of inadequate or unreasonable security protocols, the use of
excessive or unnecessary force, and the frequency of use of force incidents. The Department attempted
to create a parallel supervisory structure in order to provide more direct support to Wardens, but could
not find candidates with the appropriate skill set and/or the willingness to work within a parallel
supervisory structure. The City’s and Commissioner’s declarations in this matter (dkt. 485 and 488,

See e.g. Eleventh Monitor’s Report at pg. 15, Monitor’s Twelfth Report at pg. 13, Monitor’s
September 23, 2021 Status Letter to the Court at pg. 7.
110

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respectively) conceded the lack of success in creating a parallel supervisory structure capable of
improving facility leadership and stated that supplementing Wardens with civilian leaders was the only
viable course of action to meet the requirements of this provision.
The Court’s December 6, 2022 Order regarding Facility Supervisors (dkt. 492) created new
positions (i.e., Assistant Commissioners of Operations) 111 to replace those currently in Warden
positions. When filling these positions, the order permits the Department to look beyond uniformed
staff to the broader corrections community to ensure the candidates have the breadth of experience and
demonstrated effectiveness as leaders to accomplish the requirements of this provision. This expansion
to hiring criteria was only granted at the end of the Monitoring Period and the Department began to
recruit for the positions at the very end of 2022. Assistant Commissioners of Operations will be
installed to oversee each facility, essentially replacing the Wardens with individuals with the requisite
expertise and leadership ability to facilitate the culture change required to meet the requirements of the
Court’s orders. Five such individuals have are scheduled to begin work in April 2023.
Conclusion
The impact that the agency’s new leadership—hired from outside the uniform ranks—has
already had on practice suggests that the Department’s efforts to push this strategy further down the
chain of command and into the facilities is a promising path toward reforming the agency. As the
Department conceded in its supporting declarations for the Court’s December 2022 Order, its efforts in
this Monitoring Period were insufficient to achieve compliance with the requirements of this provision.
That being said, it is expected that the ability to achieve compliance with this provision is now within
reach with the ability to recruit and hire from a broader pool of candidates to lead the facilities. The
new Assistant Commissioners of Operations must be brought on board with all due haste. It remains to
be seen whether these individuals will be able to succeed in their core task of raising the quality of staff
practice among all ranks, including the quality of staff supervision afforded by DW, ADWs, and
Captains and the quality of security practices, crisis management and service provision delivered by
line staff. The Monitoring Team will closely monitor the continued progress toward onboarding the
new Associate Commissioners or Operations and evaluate their impact going forward.
COMPLIANCE RATING § A., ¶ 2. Non-Compliance
Remedial Order § A., ¶ 3 (Revised De-escalation Protocol)
§ A., ¶ 3. Within 90 days of the date this Order is approved and entered by the Court (“Order Date”), the
Department shall, in consultation with the Monitor, develop, adopt, and implement a revised de-escalation
protocol to be followed after Use of Force Incidents. The revised de-escalation protocol shall be designed to

The Court Order titles these positions “Facility Supervisor,” but the Department’s title “Assistant
Commissioner of Operations” is used in this report for clarity.
111

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minimize the use of intake areas to hold Incarcerated Individuals following a Use of Force Incident given the
high frequency of Use of Force Incidents in these areas during prior Reporting Periods. The revised deescalation protocol shall address: (i) when and where Incarcerated Individuals are to be transported after a Use
of Force Incident; (ii) the need to regularly observe Incarcerated Individuals who are awaiting medical treatment
or confined in cells after a Use of Force Incident, and (iii) limitations on how long Incarcerated Individuals may
be held in cells after a Use of Force Incident. The revised de-escalation protocol shall be subject to the approval
of the Monitor.

This box provides a compliance assessment on the Department’s efforts to reduce the reliance
on the use of intake in general operations pursuant to the requirements of the First Remedial Order §
A., ¶ 3. This assessment also includes references to Action Plan § (E) ¶ (3)(a) (which adopts ¶1(c) of
the Second Remedial Order regarding tracking of inter/intra facility transfers), and Action Plan § (E) ¶
(3)(b) (which requires the new leadership to address these requirements) given the interplay with the
First Remedial Order § A., ¶ 3. These provisions require the various processes that are negatively
impacting intake’s orderly operation to be identified and addressed with new procedures. The
information in this compliance assesment was also provided in the Monitor’s most recent February 3,
2023 report pgs. 26 to 35.
The Classification Manager, as required by Action Plan § (E) ¶ (3)(b), has taken the lead on
addressing the matters related to intake. The plans that have been developed in coordination and
collaboration with the Security Manager, Staffing Manager, and various leadership in each of the
Facilities and other divisions are reasonable, rooted in sound correctional practice, and incorporate
facets that make these plans feasible and sustainable.
To ascertain the Department’s progress in minimizing the use of intake, the Monitoring Team
assesses the use of force in intake, available data regarding the time individuals stay in intake areas,
and the Department’s implementation of De-escalation Units to manage individuals outside of intake.
The Monitoring Team also makes observations from site visits of intake areas and its assesments of use
of force incidents. The Department has made progress on this provision and beginning in 2022, the
Department is no longer in non-compliance with the First Remedial Order § A., ¶ 3. 112
Use of Force Incident in Intake Areas
The Monitoring Team continues to evaluate the frequency with which use of force occurs in the
intake as the Monitoring Team has long noted that a chaotic environment and longer processing times
(which are often mutually reinforcing) within intake can result in a greater frequency of the use of
force. This is why efficient processing of individuals within intake and reducing reliance on intake

The Department was in non-compliance with this provision in the Eleventh and Twelfth Monitoring
Periods. A compliance assessment was not provided for the Thirteenth Monitoring Period. The
Monitoring Team found that the Department was in Partial Compliance with this provision in the
Fourteenth Monitoring Period in the October 28, 2022 Report.
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following a use of force are so critical. While the number of uses of force within the Department is still
too high, there is at least some evidence that the improved conditions within intake have resulted in a
reduced number of uses of force. The total number of uses of force in intake in 2022 (963) is 54%
lower than the total number of uses of force in intake in 2021 (1483). Further, the proportion of uses of
force in intake has decreased instead of increased for the first time.

# of Use of Force Incidents in
Intake
Total UOF
% of UOF in Intake

Use of Force in Intake
2018
2019
Total
Total

2020
Total

2021
Total

2022
Total

913

1123

992

1483

963

5901
15%

7169
16%

6467
15%

8194
18%

7005
14%

Intake Data Tracking & NCU Audits of Individuals in Intake
Inter/intra facility transfers are required to be tracked pursuant to ¶ 1(c) of the Second Remedial
Order. As noted in the Intake section of the report, the Department has the Inmate Tracking System
which can be utilized to track inter/intra facility transfers, but facility compliance has been
inconsistent. Instead, each facility maintains a different manual tracking mechanism that does not
produce aggregate data for analysis. The Monitoring Team’s routine site visits to intake areas reveal
that intake staff are generally aware of the reasons an individual was in intake, where the individual
was waiting to go to, and the overall time they were in intake. However, the lack of a centrally
managed tracking tool limits the problem-solving effects to those within a facility, making it difficult to
promote the overall goal of ensuring that system-wide, individuals are not left in intake for long
periods of time.
Given that the Department was unable to provide valid system-wide data for individual stays in
intake in 2022, the Monitoring Team asked NCU to conduct audits of intake units across a number of
facilities beginning in January 2022 to better understand the scope of the issue for intake stays for nonnew admissions. Such audits were conducted in January and February 2022, August 2022, October
2022, November 2022, and December 2022 of Intake Areas at AMKC, GRVC, RNDC, and NIC for
non-new admissions.
As noted in the Monitor’s June 30, 2022 Report, NCU conducted 4 audits of intake areas in
three different facilities in January 2022 and February 2022 and found that 33% of individuals (15 of
45) had stays in intake longer than 24 hours. Almost half of these (7 of 15) extended beyond 72 hours.
In August 2022 NCU found that 13% of individuals (4 of 30) were held for more than 24 hours
(but all 4 were held in intake less than 48 hours); 3 of the 4 individuals were held in intake awaiting
Mental Health Housing, and one for issues with disrupting his housing unit.

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NCU conducted six audits of intake areas in four different facilities (RNDC, AMKC, NIC, and
GRVC) between October and December 2022. These audits found that 8% of individuals (4 of 53) had
stays in intake longer than 24 hours (3 of the 4 individuals were held in intake less than 48 hours and
the final individual was in intake less than 72 hours). All 4 individuals were held in intake awaiting
assignment to a housing unit.
NCU’s audits for the second half of 2022 are consistent with the Monitoring Team’s site work
and other information available to the Monitoring Team that suggest there is improvement in reducing
the length and number of overstays in intake for inter/intra facility transfers.
Reduced Reliance on Intake & De-Escalation
The Monitoring Team’s routine site visits as well as assessments of use of force incidents has
continued to reveal that staff’s reliance on intake following a use of force incident has decreased. As
part of this effort, de-escalation units were opened in each Facility by July 2022. De-escalation units
are in unoccupied housing units in each facility and have cells with secured doors, a bed, toilet, and
sink. The housing units also contain a shower. While the First Remedial Order does not require the use
of de-escalation units, the Department opened these units as one alternative for staff to use instead of
intake. The Department promulgated Directive 5016 “De-escalation Unit,” which establishes the
Department’s policy and procedures for conducting de-escalation outside of facility intakes. The policy
indicates that intake should only be used for facility transfers, court processing, discharges, and
transfers to medical appointments, cadre searches, body-scans and new admissions.
NCU conducted audits between May 2022 to December 2022 to determine how facilities are
managing individuals in custody following a use of force incident and to assess every facility’s
adherence to the de-escalation policy. Specifically, NCU reviewed Genetec video to track the
movement of individuals after a use of force incident to determine if staff is following the policy on deescalation protocol (i.e., not placing individuals in intake pens after incidents).
The NCU audits covering July to December 2022 (the Fifteenth Monitoring Period) revealed
that 88 of 124 individuals (71%) (compared with 54% in May and June 2022) were not taken to intake
and instead were taken back to their assigned cell to de-escalate, immediately rehoused, taken directly
to the clinic for medical care, or were placed in a de-escalation unit. Only 36 of 124 individuals (29%)
were brought to intake areas. This audit, in conjunction with the Monitoring Team’s own observations
from site work and evaluation of relevant information, revealed improvement in reducing the number
of individuals taken to intake pens. It also revealed that facilities are moving a greater proportion of
individuals directly back to their assigned cells, to de-escalation units or the clinic, or immediately rehousing individuals than they have in the past. It is worth noting that moving individuals back to their
assigned cell or utilizing an adequate alternative to intake is an acceptable and important component to
reducing the reliance on intake.

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Conclusion
The Department has taken important steps to reduce reliance on the use of intake after a use of
force. NCU audits, and the Monitoring Team’s work, demonstrate that the Department has made
progress in utilizing intake less for post-incident management. Further, the number of uses of force
within intake has decreased. Additional work remains as continued efforts are needed to reduce the
utilization of intake after a use of force and as described at length in the Intake section of this report,
the Department must be able to track individual stays in intake. The Monitoring Team found the
Department was in Partial Compliance with the First Remedial Order § A., ¶ 3 in the Fourteenth
Monitoring Period and given the findings above, the Department has sustained Partial Compliance in
the Fifteenth Monitoring Period,
COMPLIANCE RATING § A., ¶ 3. Partial Compliance
REMEDIAL ORDER § A., ¶ 4 (SUPERVISION OF CAPTAINS)
¶ 4. Supervision of Captains. The Department, in consultation with the Monitor, shall improve the level of supervision of
Captains by substantially increasing the number of Assistant Deputy Wardens (“ADWs”) currently assigned to the
Facilities. The increased number of ADWs assigned to each Facility shall be sufficient to adequately supervise the Housing
Area Captains in each Facility and the housing units to which those Captains are assigned, and shall be subject to the
approval of the Monitor.

This provision requires the Department to improve staff supervision by hiring and deploying
additional ADWs within the facilities to better supervise Captains. The goal of this provision is to help
compensate for the more compact chain of command in the Department (discussed in more detail in the
October 28, 2022 report at pgs. 78 to 80) by ensuring that Captains are properly supervised, coached,
and guided in order to elevate the skill sets of Captains, who in turn will better supervise the officers on
the housing unit. Since this provision went into effect in August 2020, the overall number of staff at all
ranks have declined, as demonstrated in the data provided below and discussed in the Uniform Staffing
Practices section of this report. Therefore, compliance is not simply achieved by having a certain
number of individuals in these positions. The “adequate number of ADWs” required by this provision
is a dynamic target given that the number of Correction Officers and the number of Captains change
constantly, along with the number of facilities that must be staffed and the number of people in
custody. Further, the number of COs and supervisors needed will depend on the type of housing unit.
For instance, a general population housing unit with minimum custody individuals will require
different supervision levels than a housing unit with maximum custody individuals.
ADW Assignments in the Department
The table below identifies the number and assignment of ADWs from July 2020 to December
2022. As demonstrated in the data below, the overall number of ADWs has fluctuated as has the
number of ADWs that are assigned to the Facilities or Court Commands, which require the most
engagement with the incarcerated population. It is notable that the overall number of ADWs within the

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Department and assigned to the Facilities and Court Commands has increased and that the majority
(80%) of ADWs are assigned to work in the Facilities and Court Commands. As noted above, the total
number of ADWs is important, but must be analyzed in the context of the number of Captains being
supervised by each to ascertain whether there has been improvement in the overall level of supervision.
Therefore, an analysis of the number of Captains follows.

Facility
AMKC
EMTC 114
GRVC
MDC 115
NIC
OBCC 116
RMSC
RNDC
VCBC
Court Commands
(BKDC, BXDC,
QDC)
Total # of ADWs
in Facilities &
Court
Commands
Total # of ADWs
Available
Departmentwide
% of ADWs in
Facilities &
Court
Commands

# of ADWs
As of July
18, 2020
9
0
6
6
6
6
5
7
4

Number of ADWs &
Assignments in the Department 113
# of ADWs
# of ADWs
# of ADWs
As of Jan. 2, As of June As of Jan. 1,
2021
26, 2021
2022
21
13
12
0
0
0
10
11
9
2
1
1
8
8
5
8
8
14
6
6
5
15
15
10
6
5
5

# of ADWs
As of June
18, 2022
9
0
8
0
7
7
4
7
4

# of ADWs
As of Dec.
31, 2022
12
8
12
1
8
0
5
12
5

3

4

3

3

3

3

52

80

70

64

49

66

55

95

88

80

67

82

79%

84%

80%

80%

73%

80%

As of the end of the Monitoring Period, the assignment of ADWs within the Facility is not available so
this data simply demonstrates the number of ADWs per facility.
113

EMTC has been closed and opened in these Monitoring Periods. Until late 2022, staff that work at
EMTC were technically assigned to AMKC.
114

MDC was utilized in a limited capacity at the end of the Twelfth Monitoring Period and was closed by
June 2021.
115

OBCC was slated for closure in the Fourteenth Monitoring Period and had an ADP of 81 in the month
of June 2022. OBCC was closed by July 2022. Staff were then reassigned to other commands.
116

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Captain Assignments in the Department
The table below identifies the number and assignment of ADWs from July 2020 to December
2022. As discussed above, the overall number of Captains in the Department and assigned to the
Facilities and the Court Commands has decreased. However, the Department has made progress on
maximizing the number of Captains assigned to the Facilities and Court Commands. In fact, in this
Monitoring Period, the proportion of Captains (75%) assigned to work in the Facilities and Court
Commands is the highest it has been since this work began and reflects the efforts to ensure more
Captains are assigned to the Facilities and Court Commands.

Facility
AMKC
EMTC 118
GRVC
MDC 119
NIC
OBCC 120
RMSC
RNDC
VCBC
Court Commands
(BKDC, BXDC,
QDC)
Total # of Captains
in Facilities and
Court Commands
Total # of Captains
Available
Department-wide
% of Captains in
Facilities and
Court Commands

# of
Captains
As of July
18, 2020
91
0
75
72
51
85
51
58
27

Number of Captains &
Assignments in the Department 117
# of
# of
# of Captains
Captains
Captains
As of June
As of Jan. 2,
As of Jan. 1,
26, 2021
2021
2022
111
97
87
0
0
0
72
86
86
39
15
12
45
45
56
81
78
77
50
49
36
56
60
63
25
27
25

# of
# of Captains
Captains
As of Dec.
As of June
31, 2022
18, 2022
81
80
0
38
81
90
11
11
45
50
38
7
34
31
70
70
23
22

39

37

35

32

33

28

558

523

499

474

416

427

810

765

751

670

607

573

69%

68%

66%

71%

69%

75%

As of the end of the Monitoring Period, the assignment of ADWs within the Facility is not available so
this data simply demonstrates the number of ADWs per facility.

117

EMTC has been closed and opened in these Monitoring Periods. Until late 2022, staff that work at
EMTC were technically assigned to AMKC.
118

MDC was utilized in a limited capacity at the end of the Twelfth Monitoring Period and was closed by
June 2021.
119

OBCC was slated for closure in the Fourteenth Monitoring Period and had an ADP of 81 in the month
of June 2022. OBCC was closed by July 2022. Staff were then reassigned to other commands.
120

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Assessment of Supervisor Assignments
The data above reflects that some of the steps the Department has taken to increase the level of
supervision in the jails (as discussed in the Staffing and Security Practices & Indicators section of this
report) appears to be taking shape. Further, while it is impossible to set an ideal ratio of the number of
Captains to ADWs given the issues identified above, assessing the overall ratio of Captains and ADWs
assigned to the Facilities and Court Commands is informative. To that end, the ratio of ADWs to
Captains in Facilities and Court Commands was 1 to 6.5 at the end of December 2022. This is a
significant decrease from the ratio in the last Monitoring Period which was 1 to 8.5, and an even
greater decrease from the ratio of 1 to 10.7 in July 2020 right before the Court ordered the First
Remedial Order.
It must be emphasized that the quality of the individuals who serve in these supervisory
positions is also critical to the quality of supervision provided. Increased supervision is inherently
complex and is not simply solved by increasing the number of ADWs assigned to a particular Facility.
The Monitoring Team’s findings regarding poor incident management and supervision by Captains is
what led to the recommendation to increase the deployment of ADWs throughout the Facilities. Given
that the newly promoted ADWs are drawn from the same corps of Captains who have generally
struggled with these essential skills, simply promoting additional ADWs does not solve the problem in
its entirety. Further, the Monitoring Team has raised concerns about the fitness of certain individuals
who were promoted to ADW during this Monitoring Period. More information regarding these
concerns is available in the Compliance Assessment (Screening & Assignment of Staff § XII ¶¶ 1-3)
section of this report.
The ADWs will also need substantial and quality coaching, supervision, and mentoring from
their superiors to develop into the types of supervisors that are so desperately needed in this
Department. The task of cultivating the ADWs will largely fall to the Deputy Wardens and Wardens in
each command, which brings yet another layer of complexity to the task of reforming the Department’s
practices given the issues discussed in the Security Practices & Indicators section of this report. Going
forward, the Department must make it a high priority for the Deputy Wardens and Wardens to actively
supervise and provide in-service training to these newly promoted ADWs to ensure that the quality of
the supervision improves as well. Overall, the Department has made progress in increasing the number
of supervisors available in facilities and therefore is in Partial Compliance with this Provision.
COMPLIANCE RATING § A., ¶ 4. Partial Compliance

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REMEDIAL ORDER § A., ¶ 6 (FACILITY EMERGENCY RESPONSE TEAMS)
§ A., ¶ 6. Within 90 days of the Order Date, the Department shall, in consultation with the Monitor, develop, adopt, and
implement a protocol governing the appropriate composition and deployment of the Facility Emergency Response Teams
(i.e., probe teams) in order to minimize unnecessary or avoidable Uses of Force. The new protocol shall address: (i) the
selection of Staff assigned to Facility Emergency Response Teams; (ii) the number of Staff assigned to each Facility
Emergency Response Team; (iii) the circumstances under which a Facility Emergency Response Team may be deployed
and the Tour Commander’s role in making the deployment decision; and (iv) de-escalation tactics designed to reduce
violence during a Facility Emergency Response Team response. The Department leadership shall regularly review a sample
of instances in which Facility Emergency Response Teams are deployed at each Facility to assess compliance with this
protocol. If any Staff are found to have violated the protocol, they shall be subject to either appropriate instruction or
counseling, or the Department shall seek to impose appropriate discipline. The results of such reviews shall be documented.

This provision requires the Department to minimize unnecessary or avoidable uses of force by
Emergency Response Teams. There are a few types of Emergency Response Teams: a Probe Team,
which is a team of facility-based staff; the Emergency Services Unit (“ESU”), an “elite” team of staff
specifically dedicated and trained to respond to emergencies across the Department; and Security
Response Teams (“SRT”) and Special Search Team (“SST”), which function similarly to ESU and are
deployed to facilities as part of operational security efforts. This box addresses the Monitoring Team’s
overarching concerns regarding Emergency Response Teams, provides data on the use of these teams
via facility-alarm responses, outlines steps the Department has taken to reduce reliance on these teams,
and, finally, addresses specific concerns regarding ESU.
Concerns Regarding Emergency Response Teams
The Monitoring Team has long raised concerns about the Department’s overreliance on and the
conduct of Emergency Response Teams—both at the Facility-level through the use of “Probe Teams”
and ESU (including SRT and SST which are now being used akin to ESU). 121 These concerns fall into
the following categories for all Emergency Response Teams:
•

Overreliance on these specialized teams to address issues that could and should be addressed by
either uniform staff on the housing unit or facility-level supervisors.

•

Overabundance of staff on these teams so that an excessive number of staff arrive on-scene
which often raises tensions (including chaotic nature of fielding Probe Teams using an “all call
for assistance.”).

•

Hyper-confrontational nature of these teams which often exacerbate conflict and lead to
unnecessary and/or excessive use of force.

•

Composition of these teams to ensure only those who are qualified, and do not have a history of
unnecessary and/or excessive force serve on these teams.

These concerns have been extensively laid out in the Eleventh Monitor’s Report at pgs. 38 to 50 and
116 to 120, Twelfth Monitor’s Report at pgs. 49-51, and the Second Remedial Order Report at pgs. 3-4.
121

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•

Concerning security procedures – these teams often utilize concerning security practices such
as painful escort holds.

•

These teams (and others) are also often relied upon to conduct searches, which are completed in
a manner that are inefficient and chaotic and can result in unnecessary use of force.

The concerning practices of Emergency Response Teams remain static. However, the reliance
on these teams has begun to diminish, as discussed below, which is an important first step.
Overview of Alarm Data
The table below presents the number and rate of Level A and Level B alarms for 2020, 2021,
and 2022. Level B alarm responses involve the deployment of an Emergency Response Team, while
Level A responses involve supervisors and/or de-escalation teams not suited in tactical gear. Over the
course of this three-year period, the number of Level A alarms increased while Level B alarms
decreased, and the overall rate of alarm responses declined in 2022 (a rate of 7.0 in 2022 compared
with 10.3 and 16,8 in 2021 and 2020, respectively).

Total
Alarms

#

2020
ADP

Alarms Department-Wide
2020-2022
2021
Rate
#
ADP
Rate

9,145

4,544

16.8

6,860

5,574

10.3

#

2022
ADP

Rate

4,763

5,639

7.0

#

% total

#

% total

#

% total

Level A

1,894

21%

2,264

33%

2,128

45%

Level B

7,249

79%

4,597

67%

2,635

55%

As noted in the second chart below, in 2022, a significant change occurred in this Monitoring
Period in which more Level As were utilized than Level Bs in the second half of 2022.
Alarms Department-Wide 2022
Jan.-June 2022
(14th MP)
Total
Alarms

July-Dec. 2022
(15th MP)

#

ADP

Rate

#

ADP

Rate

2,254

5,491

6.8

2,509

5,787

7.2

#

% total

#

% total

Level A

753

33%

1,375

55%

Level B

1,501

67%

1,134

45%

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The trend toward relying less on Level B responses is very positive as the Monitoring Team
continues to find that most incidents could be resolved either by the staff on the unit (no alarm
response needed) and/or their Supervisor or by calling other staff to the location in an effort to resolve
issues without using physical force (a Level A alarm).
Steps to Reduce Reliance on Emergency Response Teams
As demonstrated in the data above, there has been a decline in overall alarms and reduced
reliance on Level B alarms this Monitoring Period. A number of steps were taken this Monitoring
Period to reduce reliance on Emergency Response Teams and address other concerns with how staff
members are assigned to facility Probe Teams. The Monitoring Team’s review of all incidents through
CODs and a large proportion of Intake Investigations identifies the same reduction demonstrated in the
data. This is a significant step in the right direction, and is likely the result of work that has been
conducted by the Security Operations Manager since he started in May 2022 to better align alarm
responses with the needs of the facility. The reduced reliance on Level B alarms and alarms in general
appears to mark the beginning of a cultural shift in the jails—a shift to problem solving by on-unit staff
and supervisors, versus simply outsourcing incident response to Emergency Response Teams as has
been the historical practice. The Monitoring Team and Security Operations Manager meet bi-monthly
to discuss a range of relevant security topics and initiatives. The Security Operations Manager’s focus
on reducing Level B responses has been a constant theme—as he reports he is reinforcing to facility
leadership on a routine basis the need for more supervisory and de-escalation responses and less use of
Level B alarms. The mentorship and leadership exhibited in this area is promising.
Additionally, the work of the Staffing Manager is also expected to improve how staff are
assigned to facility Probe Teams. The new staff assignment system will create specific staff
assignments for Probe Teams on each shift and is intended to eliminate the use of an “all hands” call
for assistance when a Level B alarm is called. As facilities operationalize the new staff assignment
system, the over-abundance of staff on these teams should be reduced. The Monitoring Team intends
to scrutinize this process as it is rolled out.
While significant concerns remain about the conduct of the members of Emergency Response
Teams, efforts to reduce the reliance on their use and limit those individuals who may serve on the
Probe Team are important foundational steps to improving practice in this area. As discussed in more
detail below, one area of significant concern remains regarding the Emergency Services Unit.
ESU
The Monitoring Team recognizes the need for and supports the utilization of a specialized and
highly trained tactical squad within the Department. ESU serves this function—ESU is located
centrally outside of any specific facility, and serves all facilities. When properly utilized and deployed,
such teams can neutralize serious risks of harm to both staff and incarcerated individuals. The practices
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of ESU have been a long-standing concern of the Monitoring Team—the “Concerns Regarding
Emergency Response Teams” listed above are particularly applicable to the conduct and management
of ESU. These issues have been raised repeatedly and consistently with Department leadership since
the inception of the Consent Judgment. Unfortunately, the Monitoring Team’s numerous feedbacks to
the Department over the years have yet to catalyze the necessary change in practice within ESU. 122
This raises significant concerns about the adequacy of the leadership within ESU.
An overarching concern regarding the management of ESU has been the selection of staff for
the team, particularly the retention of staff members in the unit after cases of misconduct have been
identified. The Department’s own policy regarding ESU requires routine screening of staff on ESU to
prevent this situation. However, this screening was not historically done despite the Department’s own
policy requirements. Based on prompting from the Monitoring Team, an assessment was done in 2021
to screen all staff on both the ESU permanent and support team (approximately 200 staff total) and
remove those staff that were not appropriately suited for the unit. Based on this screening, over 50 staff
were removed from the ESU Team as they met the criteria for removal pursuant to Operations Order
24/16 “Special Unit Assignment” because they either had certain pending charges or had discipline
imposed as a result of utilizing excessive force and/or failing to report a use of force incident.
However, this cleansing of the roster did not catalyze the necessary change in practice for those
remaining in the unit, and the Monitoring Team continues to find that ESU staff exhibit problematic
behavior that should have either prevented their appointment to ESU in the first place or triggered their
removal. Further, as discussed in more detail below, the current screening process has significant flaws
and has further undermined ESU. This cycle is unacceptable.
Finally, continued vigilance in regard to the use of the taser is necessary as ESU Captains are
the only staff authorized to use the taser in the Department. The inherent danger of the taser, coupled
with ESU’s history of excessive and unnecessary use of force, in general, warrants heightened scrutiny
of any taser use. As discussed in more detail below, the use of the taser has been curtailed significantly.
- Screening and Assignment of Staff on ESU
The Monitoring Team has long found 123 that a concerning number of ESU staff have exhibited
problematic behavior that should have either prevented their appointment to ESU in the first place or
triggered their removal from the ESU Team pursuant to Operations Order 24/16 “Special Unit
Assignment.” This policy governs both the screening of staff for placement on ESU, and postassignment review which requires the removal of staff from the ESU Team, when, among other things,
disciplinary charges have been served and/or sustained related to excessive force and failure to report.
The Department has not taken sufficient steps to curtail the problematic use of force tactics utilized by

122

See Eleventh Monitor’s Report at pg. 44-51.

123

See Eleventh Monitor’s Report at pg. 45.

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ESU as demonstrated by the selection of staff for ESU who have a documented history of bad conduct
and by allowing staff who have a documented history of bad conduct while serving on ESU to remain
in the division. Staff who are assigned to this unit require deep expertise in constructive problem
solving and tactical finesse, necessitating the careful selection and ongoing evaluation of individuals
who serve in this unit. The Monitoring Team remains concerned that staff that do not uphold the
necessary characteristics for the role remain in these positions.
The Department has generally failed to implement the screening requirements for ESU as
required by its own policy. During the 15th Monitoring Period, the Department began to routinely
screen the staff on ESU—both on a rolling basis (monthly) and on a quarterly basis to identify staff for
removal as required by the policy (with the idea that the quarterly screenings are merely needed to
catch any issues that slipped through the cracks from the monthly screenings). A recent quarterly
screening (the first to take place since the first such screening which occurred in 2021) took many
months to complete, and only after prompting from the Monitoring Team, did result in some staff
being removed from the permanent and support roster for ESU. As this process rolled out, the
Monitoring Team closely monitored these screenings and shared multiple requests and feedbacks to
ensure that the screening was conducted with fidelity. However, despite significant feedback from the
Monitoring Team, the monthly and quarterly screening of ESU staff under this policy during this
Monitoring Period raised a number of concerns as many staff who do not appear to embody the
necessary qualifications for the unit are either permitted to remain on the unit or have been appointed
to the unit despite objective evidence that they are not suited for the position. In particular, the
following issues were noted:
•

•

The Results of the Screening Process Are not Being Implemented Reliably: The screening
process does not appear to have adequate oversight to ensure that the findings are appropriately
considered and implemented. In a recent screening, five staff recommended for removal were
not, in fact, removed and no explanation was given as to why they were not removed.
Integrity of Underlying Screening Considerations is Compromised: The Monitoring Team
has concerns that the screening process itself has a number of issues that compromise its
effectiveness, including:
 ESU Misconduct Goes Unidentified by ID: ID does not consistently or reliably identify
misconduct by ESU staff. The proportion of incidents that ID identifies as not requiring
charges is questionable, at best. For example, in a recent screening it was identified that
64 staff were involved in 141 use of force incidents. ID only anticipated charges for 2
staff out of this group. ID’s failure to reliably identify misconduct by ESU staff allows
staff to act with impunity.


Assessment of Staff with Pending or Substantiated Charges Seeks to Excuse Misconduct
In Assessing Fitness of Staff Member’s Placement on ESU: The Department’s reported
evaluation of pending/substantiated charges pursuant to Operations Order 24/16 appears
to be completed in a manner that, at least in some cases, avoids having to remove staff
from ESU even when the available circumstances would require removal by policy. In
particular, the Department has reported that removal of certain staff is not necessary due
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to semantic loopholes. For instance, one staff was not removed due to the Department’s
own delay in timely screening of that staff and contention that misconduct that had been
“expunged” could not be considered. Further, the Department, for the first time, relies
on a “new” definition of misconduct – “impermissible force” – which it claims does not
trigger removal because “impermissible force” is not unnecessary or excessive force.


Staff Removed from ESU due to Misconduct have been Inappropriately Reinstated: In
early 2023, 16 staff were reinstated to ESU that were removed in 2021 following the
Department’s initial screening of ESU staff pursuant to Operations Order 24/16. The
screening in 2021 was discussed in detail in the Eleventh Monitor’s Report at pgs. 45 to
46. All 16 staff that have been reinstated also had signed NPAs in late 2021 or 2022
which appear to preclude them from being appointed to the unit.

ESU Taser Use
The use of tasers has been significantly curtailed since September 2022 when the Monitoring
Team raised concerns about a surge in its usage beginning in December 2021. 124 The taser has been
used only once between September 2022 and March 2023 (the writing of this report)—the usage
occurred in January 2023 and was a taser display. The taser has not been used in drive or stun mode at
all since September 2022. Given the concerns raised, the Monitoring Team believes it is appropriate
that taser use has been curtailed, and that there was only a single taser display, and no uses in drive or
stun mode, in over a 6-month period. The Monitoring Team will continue to closely scrutinize any case
where the taser is displayed or used.
•

ESU Next Steps
Overall, the Monitoring Team’s findings suggest that the Department’s efforts to assign and
manage ESU staff are wholly inadequate. The findings above suggest that the Department’s screening
efforts, rather than improving the quality of ESU staff, are in fact serving to obscure problematic cases
or evade the removal of staff who would otherwise be ineligible to serve as required by policy.
Similarly, reinstatement of staff who were previously removed and who have recent NPAs that should
preclude re-assignment, sends a troubling message about the conduct that will be tolerated in this unit.
The Monitoring Team has recommended that the procedures in the Operations Order 24/16 must be
revised to eliminate the loopholes identified. The Monitoring Team also recommends that the
processes for screening and the individuals appointed to conduct said screenings must be improved and
have adequate oversight to ensure that the screenings are appropriate and reliable and are not
susceptible to potential malfeasance.
•

As noted in the Monitor’s October 28, 2022 Report at pg. 118, ESU began using and displaying the
taser again in December 2021 after a long hiatus, which raised serious concerns for the Monitoring Team.
However, at the behest of the Monitoring Team, significant intervention and individualized training for
ESU by the Commissioner and Security Operations Manager in August 2022 swiftly put a stop to the
increased taser use and displays. At these meetings, the proper circumstances of when a taser may be used
was discussed and it was reiterated that tasers should never be used for the purpose of pain compliance.
124

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Conclusion
Some progress has been made in regard to facility-based Probe Teams and reduced reliance on
Level B alarms, which should have the positive impact of reducing the overall chaos in the jails often
caused by overreliance on these tactical teams to address issues better served through de-escalation and
strong supervision. That said, work remains to address long-standing concerns with the conduct of
Emergency Response Teams. As noted above, the assignment and management of ESU requires
significant improvement to gain fidelity, and is a critical part of setting the right tone in the entire
agency relating to unnecessary and excessive force—that is, a zero tolerance approach. The
Department is therefore in Non-Compliance with § A., ¶ 6 of the First Remedial Order.
COMPLIANCE RATING § A., ¶ 6. Non-Compliance

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•

USE OF FORCE POLICY (CONSENT JUDGMENT § IV)

IV. USE OF FORCE POLICY ¶ 1 (NEW USE OF FORCE DIRECTIVE)
¶ 1. Within 30 days of the Effective Date, in consultation with the Monitor, the Department shall develop, adopt, and
implement a new comprehensive use of force policy with particular emphasis on permissible and impermissible uses of
force (“New Use of Force Directive”). The New Use of Force Directive shall be subject to the approval of the Monitor.

This provision of the Consent Judgment requires the Department to develop, adopt, and
implement a comprehensive Use of Force Policy with particular emphasis on permissible and
impermissible uses of force. The Department previously achieved Substantial Compliance with the
development and adoption of the Use of Force Policy, which received the Monitor’s approval prior to
the Effective Date of the Consent Judgment in 2015.
Standalone Policies
The Department maintains a number of standalone policies, along with the UOF policy,
regarding the proper use of security and therapeutic restraints, spit masks, hands-on-techniques,
chemical agents, electronic immobilizing devices, kinetic energy devices used by the Department,
batons, lethal force, and canines. ESU also maintains about 10 Command Level Orders (“CLOs”),
including two which govern the use of specialized chemical agent tools (i.e., Pepperball system and the
Sabre Phantom Fog Aerosol Grenades). In at least some cases, these CLOs lack sufficient guidance on
the tools’ place in the use of force continuum, and need to be updated to address feedback from the
Monitoring Team. The Monitoring Team has brought the issue of these outdated CLOs to the Security
Operations Manager’s attention for revisions.
Implementation of UOF Policy
A comprehensive overview of the Department’s use of force is examined in the Security
Practices and Indicators Section of the report. The information and findings in that section inform this
compliance assessment.
As noted in the Security Practices & Indicators section of this report, there has been some
progress made in improving the operations of the jails and the rate of UOF has decreased from its apex
in 2021. However, the work completed to date has not appreciably improved the Department’s security
practices and the Department’s problematic approach to using force Department-wide. For example, in
2022, facility leadership (via Rapid Reviews) identified that 48% of use of force incidents involved
procedural errors (e.g., failure to secure doors, failure to apply restraints properly), some of which
directly contributed to the circumstances that facilitated the incident. This, coupled with the 16% of
incidents that were determined to be “avoidable,” demonstrates that even the Department’s internal
analysis shows that staff are not applying the requisite skill set and decision-making needed to decrease
the use of force rate.
Elements of the Action Plan, including the various staff supervision and security initiatives
described throughout this report, should result in significantly lower levels of violence and use of force
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if properly implemented. It remains to be seen if the Department can successfully improve the quality
of its security practices and reduce the overall frequency with which force is used to meet the
overarching goals of the Consent Judgment. In the meantime, the Department remains in NonCompliance with the implementation of the Use of Force Policy.

COMPLIANCE RATING

¶ 1. (Develop) Substantial Compliance
¶ 1. (Adopt) Substantial Compliance
¶ 1. (Implement) Non-Compliance
¶ 1. (Monitor Approval) Substantial Compliance

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•

USE OF FORCE REPORTING AND TRACKING (CONSENT JUDGMENT § V)

V. USE OF FORCE REPORTING AND TRACKING ¶ 2 (INDEPENDENT STAFF REPORTS)
¶ 2. Every Staff Member who engages in the Use of Force, is alleged to have engaged in the Use of Force, or witnesses a
Use of Force Incident, shall independently prepare and submit a complete and accurate written report (“Use of Force
Report”) to his or her Supervisor.

The Department is required to report when force is used accurately and timely as part of their
overall goal to manage use of force effectively. The assessment below covers five critical areas related
to reporting force: notifying Supervisors that a use of force occurred, submission of complete,
independent and timely reports, the classification of UOF incidents, allegations of use of force, and
reporting of use of force by non-DOC staff who either witnessed the incident and/or are relaying
reports from incarcerated individuals.
Notifying Supervisor of UOF
From July to December 2022, 3,883 use of force incidents were reported by supervisors to the
Central Operations Desk and slightly over 7,700 use of force or use of force witness reports were
submitted for incidents occurring in this Monitoring Period. To assess whether staff are timely and
reliably notifying a supervisor of a UOF, the Monitoring Team considers whether there is evidence that
staff are not reporting force as required. This includes consideration of allegations as well as reports
from outside stakeholders (e.g., H+H and LAS) about potential unreported UOF. These sources
suggest that unreported uses of force are an infrequent occurrence. In this Monitoring Period, 22 out of
the 23 reports from H+H staff alleging UOF were already under investigation by ID before H+H’s
reports were submitted. In prior Monitoring Periods, the Monitoring Team has also routinely reviewed
allegations by LAS and found that most of those allegations were previously reported before the
allegation was submitted. This further reinforces that staff are routinely and consistently reporting UOF
and there are only a small number of incidents that appear to go unreported. Of those incidents that
have gone unreported, many appear to be minor UOF incidents, and instances of unreported excessive
or unnecessary force are rare.
Independent, Complete, and Timely Staff Reports
Staff members are required to submit independent and complete UOF reports. The
Department’s Use of Force Directive requires staff to independently prepare a staff report or Use of
Force Witness Report if they employ, witness, or are alleged to have employed or witnessed force. The
total volume of reports submitted (over 7,700 reports in this Monitoring Period) indicate that rare
reporting as required. Further, the Monitoring Team’s review of a large sample of reports demonstrates
that staff reports are generally independently prepared. However, the quality of reports has long varied,
and staff’s practices are consistent with those from prior Monitoring Periods (see e.g., Ninth Monitor’s
Report at pgs. 89-91). The Monitoring Team continues to read reports that are incomplete, inconsistent
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with other evidence, or too vague. Of the 3,878 Intake Investigations closed in this Monitoring Period
(covering incidents occurring between April 2022 and December 2022), ID identified 437 incidents
(11%) to have report writing issues. This is a reduction in the proportion of cases found with reporting
issues in prior Monitoring Period. However, as noted in other sections of this report, ID’s ability to
identify potential violations has decreased, and therefore it is likely that additional cases with reporting
violations may be present but were not identified. This may indicate ID is not identifying all reporting
issues and thus, the issue may be underreported. Staff reports are an integral part of a use of force
investigations, and it is therefore important that staff describe their recollection of events in their own
words and specify the exact tactics used (e.g., where on the incarcerated individual’s body the staff
member’s hands or arms were placed).
Staff members are also required to submit their reports as soon as practicable after the use of
force incident, or the allegation of the use of force unless the staff member is unable to prepare a report
within this timeframe due to injury or other exceptional circumstances. The table below demonstrates
the number and timeliness of staff reports for actual and alleged UOF from 2018 to December 2022.
Timeliness of Staff Report
Actual UOF

Alleged UOF

Year

Total Staff
Reports
Expected

Reports
Uploaded
Timely

% Uploaded
within 24
Hours

Total Staff
Reports
Expected

Reports
Uploaded
Timely

% Uploaded within
72 Hours of the
Allegation

Jan. to
Dec. 2018

15,172

12,709 125

83.77%

139

125 126

89.93%

Jan. to
Dec. 2019

21,595

20,302

94.01%

190

134

70.53%

Jan. to
Dec. 2020

19,272

17,634

91.50%

136

94

69.12%

Jan to
Dec. 2021

22,103

17,064

77.20%

111

45

40.54%

Jan to
Dec. 2022

17,700

14,776

83.48%

93

42

45.16%

125

NCU began the process of auditing actual UOF reports in February 2018.

126

NCU began collecting data for UOF allegations in May 2018.

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Jan to
June 2022

8,472

6,992

82.53%

45

19

42.22%

July to
Dec. 2022

9,228

7,784

84.35%

48

23

47.92%

As the chart above demonstrates, 2022 saw an increase in the number of reports submitted
timely, though the number of cases submitted within 24 hours has not gone back to the levels prior to
the onslaught of the staffing crisis in 2021. Specifically, in this Monitoring Period, 7,784 (84%) of the
expected 9,227 reports for actual UOF incidents were submitted within 24 hours. Further, the
Department reports that 88% of all reports were submitted within 2 days of the incident.
As for the reports for allegations of uses of force, fewer reports are being submitted within 72
hours of the allegation as required. 23 (48%) of the 48 reports for alleged UOF incidents were
submitted within 72 hours. Obtaining reports for allegations does take more time as the alleged staff
members involved must be identified and advised that a report is necessary and then the report must be
produced. The staff member may or may not be working on the day in which the allegation is received
and reviewed, so it generally takes longer to obtain reports of allegations. That said, the time to obtain
reports for allegations must improve.
The Department has continued to maintain a centralized, reliable, and consistent process for
submitting and tracking UOF Reports, which has also supported the Department’s ability to
consistently report out on its progress with respect to submission of UOF reports. The number of
reports submitted by staff is tremendous and the majority of those reports are submitted and uploaded
in a timely fashion. Overall, the Intake Investigations of UOF incidents appeared to generally have
access to staff and witness reports with enough time to conduct the investigations.
Classification of UOF Incidents
The Department is required to immediately classify all use of force incidents as Class A, B, C,
or P when an incident is reported to the Central Operations Desk (“COD”). Class P is a temporary
classification used to describe use of force incidents where there is not enough information available at
the time of the report to COD to receive an injury classification of Class A, B, or C.
The chart below identifies the Monitoring Team’s assessment of a sample of the Department’s
incident classifications from March 2016 to December 2022.

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COD Sets 127
Reviewed

Jan. to
Mar. 2016
Dec. 2018
to July 2017 th
6 & 7th
2nd to 4th MP
MP

Jan. to
Jan. to
Jan. to
Jan. to
Jan. to July to
Dec. 2019 Dec. 2020 Dec. 2021 Dec. 2022 June
Dec.
8th & 9th 10th & 11th 12th & 13th 14th &
2022
2022
MP
MP
MP
15th MP 14th MP 15th MP

Total Incidents
Reviewed

2,764

929

1,052

1,094

1,644

1,585

709

876

Total Incidents
Classified Within
COD Period 128

3,036
(97%)

909
(98%)

1,023
(97%)

1,079
(99%)

1,226
(75%)

1,238
(78%)

504
(71%)

734
(84%)

Number of
Incidents that
were not
classified within
the COD Period

88
(3%)

20
(2%)

29
(3%)

15
(1%)

418
(25%)

347
(22%)

205
(29%)

142
(16%)

The Department has continued to improve its ability to classify incidents in a timely manner
following a significant backslide in 2021. The Department reported that the delays in classifying
incidents were due to delays by H+H in updating injury reports and facilities failing to obtain these
updates within the prescribed five-day time frame. These delays also resulted in delays in the
production of information to the Monitoring Team as certain reports could not be finalized until the
incidents were fully classified. These delays, seen mainly in 2021 and early 2022, have generally been
abated and most, if not all, reports are now provided in a timely manner and the Monitoring Team is no
longer waiting for final UOF classifications cases as much as it did in the past.
As demonstrated in the chart above, in July to December 2022, 84% of all incidents were
classified within the COD period. This reflects improvement compared with the last Monitoring Period
in which 71% of incidents were classified within the COD period. While incidents were classified in a
timely manner compared to the previous Monitoring Period, the classification timing is not yet
consistent with the timeliness of classification seen prior to 2021. The Monitoring Team is cautiously
optimistic about the improvement and believes that the Department is in a position to classify incidents
in a timely manner at the rate it had in the past. However, this will require the Department to continue
to scrutinize all incidents not yet classified and ensure stakeholders are working to address deficiencies

127

This audit was not conducted in the First or Fifth Monitoring Periods.

The data is maintained in a manner that is most reasonably assessed in a two-week period (“COD
Period”). The Monitoring Team did not conduct an analysis on the specific date of reclassification
because the overall finding of reclassification within two weeks or less is sufficient to demonstrate
compliance.
128

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where they are found. The Monitoring Team will continue to closely evaluate the classification of UOF
incidents.
Alleged Use of Force
Understanding the scope of the force utilized within the Department requires consideration of
all force reported by staff and any substantiated allegations of use of force. Therefore, the Department
separately tracks all allegations of uses of force, which are claims that staff used force against an
incarcerated individual and the force was not previously reported by staff. An allegation that a use of
force occurred does not always mean that force was actually used—that is determined through the
investigations process.
The number of allegations has declined since 2016, however, there was a minor uptick in 2021
(n=210) and 2022 (n=233) from the all-time low in 2020 (n=208) as demonstrated in the chart below.

Use of Force Allegations
500
450
400
350
300
250
200

471

436

393

331

150
100

208

210

233

2020

2021

2022

50
0

2016

2017

2018

2019

Overall, the number of allegations of force is small compared to the total number of uses of
force reported by staff. In 2022, there were 233 allegations of force while 7,234 uses of force were
reported by staff. The Monitoring Team has found that generally, of the small group of allegations,
only a fraction is substantiated, and they are typically for failing to report minor uses of force, and
instances of excessive or unnecessary unreported uses of force are rare. That said, all allegations of use
of force can and must be appropriately investigated.
Non-DOC Staff Reporting
Non-DOC staff members who witness a use of force incident are required to report the incident
in writing directly to a supervisor and medical staff are required to report to a supervisor when they

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have reason to suspect that an Inmate has sustained injuries due to a use of force, but the injury was not
identified as such to the medical staff.
DOE Staff Reporting: In-person school resumed in the jail after being suspended due to COVID-19 on
April 19, 2021. The Department of Education (“DOE”) previously developed staff training and
reporting procedures, in consultation with the Monitoring Team, to address the requirements of this
provision and the December 4, 2019, Court Order (dkt. entry 334) clarifying the requirement for DOE
to submit reports. The Monitoring Team has not received any reports from DOE staff that may have
witnessed a UOF since school resumed in April 2021. In this Monitoring Period there were 3 use of
force incidents in the school and a total of 8 incidents in all of 2022 that occurred in school areas.
Although a very small number, it does suggest that at least some reports by DOE staff would be
expected. The Monitoring Team intends to evaluate whether DOE staff are reporting as required in the
subsequent Monitoring Period.
H+H Reporting: New York City Health + Hospitals (“H+H”) (the healthcare provider for incarcerated
individuals in DOC custody) has maintained a process for staff reporting. H+H staff submitted a total
of 23 reports in this Monitoring Period; 16 reports were H+H witness reports of UOF incidents and 7
reports relayed UOF allegations from an incarcerated individual. The chart provides an overview of the
reports provided by H+H staff since July of 2017.
Submission of H+H Staff Reports

Total Reports
Submitted
Total UOF
Incidents
Covered
Number of
witness
reports
submitted

July to
Dec. 2017
(5th MP)

2018
(6th & 7th
MP)

2019
(8th & 9th
MP)

2020
2021
(10th &
(12th & 13th
11th MP)
MP)
Grand Totals

2022
(14th &
15th MP)

Jan to
July to Dec
June 2022
2022
(14th MP) (15th MP)

2

53

39

56

97

52

29

23

2

53

38

46

85

42

21

21

70

36

20

16

Witness Reports
0

29

18

45

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Number of
actual or
alleged UOF
incidents
covered by
submitted
reports
Number of
reports of
allegations of
UOF relayed
from an
Incarcerated
Individuals
Number of
actual or
alleged UOF
incidents
covered by
submitted
reports

0

31

15

36

64 129

25 130

11 131

14

Relayed Allegations from Incarcerated Individuals

2

24

21

11

27

16

9

7

2

22

23

10

22 132

19 133

12 134

7

It is difficult to know whether H+H staff submitted reports in every incident witnessed. First, in
this Monitoring Period, 225 incidents occurred in clinic areas and 7 of those incidents had a
corresponding H+H report. However, just because an incident occurred in the clinic area does not
mean H+H staff witnessed the incident. That said, the reduction in the number of reports submitted in
2022 (n=52) compared to 2021 (n=97) further suggests that there is room for improvement in the
submission of reports. Further, it is worth noting that H+H submitted reports for 14 incidents that were
categorized as occurring in other parts of the jail where a participant was later taken to the clinic and
additional force was witnessed or relayed. Still, it would be expected that at least some H+H staff
observed more force than what has been reported.
Conclusion
The requirements related to reporting use of force are multi-faceted. Overall, use of force
incidents that occur are being reported as required, but the time to classify incidents still needs to be

On one occasion for one use of force incident, we received both a witness report and a relayed
allegation report for the same incident.
129

On two separate occasions for two separate use of force incidents, we received both a witness report
and a relayed allegation report for the same incident.
130

131

See id.

132

See id.

133

See id.

134

See id.

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improved. Further, thousands of individual staff reports are submitted, most of which are submitted in
a timely manner, but improvement is needed in the substance of these to reliably and consistently
report what occurred. The Department is therefore in Partial Compliance with this requirement.
COMPLIANCE RATING

¶ 2. Partial Compliance

V. USE OF FORCE REPORTING AND TRACKING ¶ 22 (PROVIDING MEDICAL ATTENTION FOLLOWING
USE OF FORCE INCIDENT)
¶ 22. All Staff Members and Inmates upon whom force is used, or who used force, shall receive medical attention by
medical staff as soon as practicable following a Use of Force Incident. If the Inmate or Staff Member refuses medical care,
the Inmate or Staff Member shall be asked to sign a form in the presence of medical staff documenting that medical care
was offered to the individual, that the individual refused the care, and the reason given for refusing, if any.

Staff members and incarcerated individuals upon whom force is used, or who used force, are
required to receive medical attention by medical staff as soon as practicable following a Use of Force
Incident. The Department’s progress in providing timely medical care from January 2018 to December
2022 following a UOF are outlined in the table below.

2018

Wait Times for Medical Treatment Following a UOF
# of Medical
Between 2
% Seen
Between 4
2 hours or
Encounters
and 4
within 4
and 6
less
Analyzed
hours
hours
hours
9,345
37%
36%
73%
16%

6 hours or
more
13%

2019

11,809

43%

38%

81%

11%

9%

2020

10,812

46%

36%

82%

10%

9%

2021

14,745

39%

30%

70%

11%

20%

2022
2022
(Jan. to June)
2022
(Jul. to Dec.)

12,696

51%

23%

74%

9%

19%

5,986

46%

25%

71%

10%

20%

6,710

56%

20%

76%

8%

17%

During the current Monitoring Period, there were 6,710 medical encounters related to a UOF.
The time to provide medical treatment has improved in this Monitoring Period where 76% of all cases
were seen within 4 hours of the incident compared with the last Monitoring Period in which 71% of all
cases were seen within 4 hours of the incident. As a result, the proportion of cases in which an
individual was seen beyond 4 hours of the incident has decreased with 8% of medical encounters
occurring between 4 and 6 hours of the incident, and 17% of medical encounters occurring beyond 6
hours. While the time to provide medical treatment has improved in 2022 compared to 2021, the
overall provision of medical treatment within 4 hours has decreased since the peak in 2020 where 82%
of medical encounters were completed within 4 hours of the incident. The Department has reported that
staffing issues, which increased exponentially in 2021, are to blame for some of these issues. This is
yet another reason why addressing the staffing issues should produce a corresponding improvement in
operations including ensuring that individuals receive prompt medical treatment. Provision of prompt
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medical treatment is critical and so the Department must continue to work to ensure staff members and
incarcerated individuals receive prompt medical attention.
COMPLIANCE RATING

¶ 22. Partial Compliance

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•

USE OF FORCE INVESTIGATIONS (CONSENT JUDGMENT § VII)
The Investigation Division (“ID”) plays a crucial role in the reform effort. Investigations

by ID must be able to assess use of force incidents and identify violations of the Use of Force
Directive (and other relevant policies underlying the Court orders in this case) consistently and
reliably. This is critical to ensuring that staff are held accountable for misconduct. Upon a
finding of potential misconduct, a range of accountability options may be utilized with staff
including corrective interviews and counseling, retraining, and more traditional forms of
discipline (such as relinquishing compensatory days). Further, ID’s role is crucial in identifying
those cases where immediate action must be taken, and identifying when staff's contact with
persons in custody should be limited. Because discipline is still generally protracted, the need for
identifying those cases that require immediate corrective action is particularly important.
As noted in the Introduction to the report, there was a marked decline in quality in
investigations in 2022. The Department’s ability to investigate use of force incidents is one area
where there had been significant improvement since the effective date of the Consent Judgment.
ID is responsible for investigating all use of force incidents. 135 Every use of force incident
undergoes an initial assessment, called an Intake Investigation, to determine whether any
indicators of misconduct are present that require additional investigation.136 Within ID, an entire
unit of investigators (the Intake Squad) is dedicated to conducting Intake Investigations as
required by the First Remedial Order. If the Intake Investigation is of reasonable quality, most

The Consent Judgment originally envisioned a role for facilities in conducting certain investigations,
but that no longer occurs.
135

As described in the Ninth Monitor’s Report at pgs. 41-47. Intake Investigations are a more streamlined
approach to the initial assessment that their predecessor, “Preliminary Reviews.”
136

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incidents can and should be resolved at this stage with only a subset requiring referral for further
investigation (“Full ID investigation”). The creation of and proper deployment of the Intake
Squad was one of the tools that helped to address the massive backlog 137 of investigations of use
of force incidents that hampered ID and delayed accountability for staff misconduct. The backlog
was resolved in May 2021. 138
The elimination of the backlog, in combination with the structural changes made to the
way investigations were conducted and the creation of the Intake Squad, had an immediate
positive impact on ID’s work. The quality of Intake Investigations and Full ID Investigations
began to improve, and cases were no longer lost to the statute of limitations.139 Along with these
practice improvements, ID’s compliance with the requirements of the Consent Judgment also
improved. First, in 2020, during the 10th Monitoring Period, ID moved out of Non-Compliance
and was found to be in Partial Compliance with the requirement to conduct thorough, timely, and
objective investigations of use of force incidents (Consent Judgment §VII., ¶ 1). ID maintained
Partial Compliance through the 14th Monitoring Period. 140 During the second half of 2020, ID

The backlog of ID investigation was defined as any investigation of an incident that occurred on or
before April 16, 2020. See Remedial Order, § B., ¶ 1.
137

As described in the Monitor’s Second Remedial Order Report filed with the Court on June 3, 2021,
(dkt. 373).
138

As described in the Eighth Monitor’s Report at pgs. 131-134, due to the backlog, approximately 2,000
investigations of use of force incidents were still pending when the statute of limitations for any
misconduct stemming from the incident had expired. Therefore, to the extent that these cases involved
misconduct, that misconduct went unaddressed.

139

A compliance rating for this provision was suspended in the 13th Monitoring Period and provided in
the 14th Monitoring Period. The Monitoring Team did not assess compliance with any provisions of the
Consent Judgment or Remedial Orders for the period between July 1, 2021 and December 31, 2021 (the
“Thirteenth Monitoring Period”). The Court suspended the Monitoring Team’s compliance assessment
during the Thirteenth Monitoring Period because the conditions in the jails during that time were detailed
to the Court in seven status reports (filed between August and December 2021), a Remedial Order Report

140

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further leveraged these improvements and was found in Substantial Compliance with the
requirements regarding Intake Investigations (née Preliminary Reviews) (Consent Judgment
§VII., ¶ 7) in the 11th and 12th Monitoring Periods. Finally, from the inception of the Consent
Judgment, ID consistently referred cases for Full ID investigations as required (Consent
Judgment §VII., ¶ 8) and was found in Substantial Compliance with this requirement from the
2nd Monitoring Period through the 12th Monitoring Period. 141
Unfortunately, during the current Monitoring Period a marked shift in the quality of
investigations occurred. The Monitoring Team observed that a substandard approach was often
taken in assessing evidence such that the ultimate quality of the investigations was compromised.
The Monitoring Team was very concerned that ID’s previously documented progress had
degraded. Issues identified included a greater number of Intake Investigations that were closed
with no action, a significantly smaller number of cases were referred for further investigation via
a Full ID Investigation, and misconduct was identified much less frequently than in the past.
As discussed in more detail below, the proportion of use of force related misconduct
identified by ID during the past year (in particular, during the second half of 2022) decreased
from prior years. However, the Monitoring Team did not identify a corresponding change in staff
practices that would warrant or explain the decrease in the volume of use of force related
misconduct identified by ID. The Monitoring Team’s assessment of thousands of UOF incidents

(filed on December 22, 2022) as well as in the Special Report filed on March 16, 2022 (dkt. 441). The
basis for the suspension of compliance ratings was also outlined in pgs. 73 to 74 of the March 16, 2022
Special Report (dkt. 438).
Compliance ratings for these provisions were suspended in the 13th to 15th Monitoring Periods. 13th
Monitoring Period compliance ratings were suspended as noted in the footnote above. Regarding the 14th
and 15th Monitoring Periods, § G., ¶ 5 of the Action Plan suspended the Monitoring Team’s assignment of
compliance ratings for Consent Judgment § VII., ¶¶ 7 and 8 (and all other provisions not specifically
enumerated) from January 1 – December 31, 2022.
141

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in 2022 continues to demonstrate that the well-documented patterns and practices of use of force
related misconduct continues without any appreciable improvement. Therefore, ID’s failure to
adequately identify and address such issues simply undermines the Department’s ability to hold
staff accountable and inhibits efforts to address and improve poor practice.
The Monitoring Team’s assessment of the new leadership in ID (the Deputy
Commissioner of Investigations)—installed in summer 2022—revealed a basis for significant
concern. The Monitoring Team observed a shift in practice that suggested that staff may have
been influenced or prompted, either overtly or implicitly, to adopt a more lenient approach when
assessing certain cases and to change their practices in ways that compromised the quality of the
investigations. The Monitoring Team also observed that oversight of investigations and
supervisors was not as rigorous as it should be and that morale within the Investigation Division
deteriorated with a large number of staff recently leaving the Division (particularly in early
2023). Of serious concern to the Monitoring Team is that some staff reported that they did not
feel comfortable speaking openly and candidly with the Monitor because of fear of reprisal by
the Deputy Commissioner of Investigations were he to learn of such communications.
In response to the Monitoring Team’s findings (more detail and information is provided
in the compliance discussion below), the Department has recently taken a number of steps. First,
the Deputy Commissioner of ID has resigned, and the Commissioner has appointed a new
interim Deputy Commissioner of ID. 142 Recruiting for a new permanent Deputy Commissioner
of ID has begun. Second, a group of well-qualified ID supervisors conducted a re-assessment of

The Monitoring Team has worked with the interim Acting Deputy Commissioner of ID over the last
year in various capacities. She has proactively engaged with the Monitoring Team on numerous issues. It
is expected that this leadership change will result in a more collaborative and transparent relationship
between the Monitoring Team and ID’s staff.
142

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certain cases to identify any that may merit additional scrutiny. Those cases were re-opened for
investigations. Third, the Associate Commissioner of ID, a well-respected and seasoned
investigator and supervisor, will be directly overseeing use of force investigations going forward.
Further, training will be revised, and a quality assurance division has been created to assess those
use of force investigations that are closed with no action. The Department is currently
collaborating with the Monitoring Team to refine these initiatives. The Department also reports
that it is working with the City to improve its ability to recruit new investigators for the Division
by seeking to provide more competitive benefits. The Monitoring Team strongly encourages the
Rikers City Task force to support these efforts with all necessary resources and all due haste. The
Monitoring Team also recommends that the Department provide in a timely manner appropriate
communications directing investigators and supervisors that investigations are to be conducted
without fear or favor, that the requirements of the Consent Judgment are to be adhered to, and
that all staff within ID are encouraged to work collaboratively with the Monitoring Team.
The decline in the quality of ID’s investigations was alarming. However, the Monitoring
Team is encouraged that the Department has taken steps to mitigate any further decline in the
quality of investigations and to restore the Division’s previous progress towards achieving
compliance. In particular, the Commissioner’s decision and action to change leadership within
ID is expected to convey an important message about the expectations for the ID staff going
forward, including adherence to the requirements of the Court’s orders. The steps being taken are
concrete and appropriate. The Monitoring Team intends to work closely with the new leadership
in ID to collaborate on the initiatives to reinstate past practices and will continue to closely
scrutinize the work of ID. As this work is ongoing, the Monitoring Team intends to share further
updates with the Court in its April 25, 2023 status report and subsequent reports.

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VII. USE OF FORCE INVESTIGATIONS ¶ 1 (THOROUGH, TIMELY, OBJECTIVE INVESTIGATIONS) &
¶ 9 (A) (TIMING OF FULL ID INVESTIGATIONS)
¶ 1. As set forth below, the Department shall conduct thorough, timely, and objective investigations of all Use of Force
Incidents to determine whether Staff engaged in the excessive or unnecessary Use of Force or otherwise failed to comply with
the New Use of Force Directive. At the conclusion of the investigation, the Department shall prepare complete and detailed
reports summarizing the findings of the investigation, the basis for these findings, and any recommended disciplinary actions
or other remedial measures. All investigative steps shall be documented.
¶ 9. All Full ID Investigations shall satisfy the following criteria [. . . as enumerated in the following provisions]:
a.
Timeliness [. . .]
ii.

Beginning on October 1, 2018, or three years after the Effective Date, whichever is earlier, and for
the duration of the Agreement:
1.

ID shall complete all Full ID Investigations by no later than 120 days from the Referral
Date, absent extenuating circumstances outside the Department’s control that warrant an
extension of this deadline. Any extension of the 120-day deadline shall be documented
and subject to approval by the DCID or a designated Assistant Commissioner. Any Full
ID Investigation that is open for more than 120 days shall be subject to monthly reviews
by the DCID or a designated Assistant Commissioner to determine the status of the
investigation and ensure that all reasonable efforts are being made to expeditiously
complete the investigation.

2.

The Department shall make every effort to complete Full ID Investigations of less
complex cases within a significantly shorter period than the 120-day time frame set forth
in the preceding subparagraph.

This compliance assessment provides an overview of the status of investigations for all UOF
incidents through December 31, 2022. This includes an assessment of the quality and timing of Intake
Investigations and Full ID Investigations, the status of ID staffing, the status of law enforcement referrals
for potential criminal misconduct, and details about the Use of Force Priority Squad.
Status of Investigations
The table below provides, as of January 15, 2023, the investigation status of all UOF incidents
that occurred between January 2018 and December 2022. 143 ID continues to investigate an enormous
volume of cases. All use of force cases receive an Intake Investigation (formerly called Preliminary
Reviews) and a subset of those cases are then referred for Full ID Investigations where a more in-depth
investigation occurs. The timing to complete investigations, the quality of investigations, and their
outcomes are discussed in more detail below.

143

All investigations of incidents that occurred prior to 2018 have been closed.

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Investigation Status of UOF Incidents Occurring Between January 2018 and December 2022
as of January 15, 2023
Jan. to June July to Dec.
2022
2022
(14th MP)
(15th MP)

Incident Date

2018

2019

2020

2021

2022

Total UOF
Incidents 144

6,302

7,494

6,399

8,413

7,226

3,349

3,877

Pending
Intake Invest.

0

0%

0

0%

0

0%

0

0%

440

6%

1

<1%

439

11%

Pending Full
ID Invest.

0

0%

0

0%

0

0%

1

<1%

359

5%

204

6%

155

4%

Total Closed
Invest.

6,302

100%

7,494

100%

6,399

100%

8,412

~100%

6,427

89% 3,144 94% 3,283 85%

Intake Investigations
All use of force incidents that occurred during this Monitoring Period received an Intake
Investigation. Outlined below is an assessment of those Intake Investigations.
•

•

Timing to Close Intake Investigations: Intake Investigations are required to be completed within
25 business days of the incident date. During this Monitoring Period, all but a handful of cases
were closed within 30 business days of the incident, which is beyond the deadline, but is only a
minor deviation from the 25-business day deadline, so it is not cause for concern. Less than 1% of
all Intake Investigations were closed beyond 30 business days.
Outcome of Intake Investigations: Intake Investigations can be closed with no action, by referring
the case for further investigation via a Full ID investigation, or by referring the case for some type
of action (e.g., MOC, PDR, Re-Training, Facility Referral). With respect to cases closed with no
action, in some, the violation identified by ID had already been identified by the Facility via
Rapid Review and ID determined that the recommended action by the Rapid Review was
sufficient to address the violation. Therefore, “no action” cases are better understood as cases in
which ID took no action. 145 As discussed further below, the proportion of incidents with certain
outcomes changed sharply during the 15th Monitoring Period, compared to all prior Monitoring

Incidents are categorized by the date they occurred, or date they were alleged to have occurred,
therefore these numbers fluctuate very slightly across Monitoring Periods as allegations may be made
many months after they were alleged to have occurred and totals are updated later.
144

Cases that close with no action may have been addressed by the Facility through Rapid Reviews. ID
analyzed almost 1,000 Intake Investigations closed with no action this Monitoring Period and determined
that the facilities took action in 46% of them, including 5003 counseling, verbal counseling, corrective
interviews, or Command Disciplines.
145

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Periods since the inception of the Intake Squad. More specifically, significantly more cases were
closed with no action (56% during the current Monitoring Period, compared to an average of 42%
in prior Monitoring Periods), and significantly fewer cases were referred for Full ID
Investigations (only 2% in the current Monitoring period, compared to an average of 15% in prior
Monitoring Periods).
Outcome of Intake Investigations 146
as of January 31, 2023 147
Incident Date
Pending Intake
Investigation
Closed Intake
Investigation
No Action
MOC
PDR
Re-Training
Facility Referrals
Referred for Full
ID
Data Entry
Errors
Total Intake
Investigations

Feb. 3 148 to
June 2020
(10th MP)

July to
Dec. 2020
(11th MP)

Jan. to
June 2021
(12th MP)

July to
Dec. 2021
(13th MP)

Jan. to
June 2022
(14th MP)

July to
Dec. 2022
(15th MP)

0

0

0

0

0

352

2,492

3,272

4,468

3,916

3,352

3,550

1,060
43%
47
2%
6
148
6%
820
33%

1,279
39%
28
1%
2
226
7%
1,159
35%

1,386
31%
48
1%
0
342
8%
1,903
43%

947
24%
36
1%
0
91
2%
2,208
56%

1,249
37%
22
1%
1
35
1%
1,637
49%

1,984
56%
54
2%
3
36
1%
1,389
39%

411
12%

567
17%

781
17%

634
16%

360
11%

84
2%

48 149
2,492

3,272

4,468

3,916

3,352

3,902

It is important to note that the results of the Intake Investigations, for the purpose of this chart, only
identify the highest level of recommended action for each investigation. For example, while a case may
be closed with an MOC and a Facility Referral, the result of the investigation will be classified as “Closed
with an MOC” in the chart below.
146

Other investigation data is this report is reported as of January 15, 2023 while the Intake Investigation
data is also reported as of January31, 2023 because the data is maintained in two different trackers that
were produced on two different dates. The number of pending Intake cases therefore varies between data
provided “as of January 15, 2023” and “as of January 31, 2023,” depending on which tracker was utilized
to develop the necessary data.
147

Incidents beginning February 3, 2020 received Intake Investigations, so those incidents from the early
part of the Tenth Monitoring Period are not included in this data.
148

These investigations had data entry errors in the Intake Squad Tracker. The Monitoring Team is unable
to determine the outcome for these cases but is working with the Department to fix these errors.
149

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o Action Taken Following Close of Intake Investigations: While the number of referrals for
formal discipline (via an MOC) by the Intake Investigation increased during this
Monitoring Period and almost doubled from the previous Monitoring Period (54 versus
22), this does not reflect an overall increase in the number of disciplinary referrals from
ID. The increase in referrals for formal discipline via Intake Investigations does not offset
the significant decrease in referrals for formal discipline following the conclusion of Full
ID cases—as discussed in more detail later in this section of the report. There was a
significant decrease in the number of referrals for Full ID investigations (where most
formal discipline is identified and addressed through charges), which likely compounded
the lack of overall formal disciplinary referrals from ID. Finally, the number of cases
referred for re-training has steadily decreased to less than 5% of all cases.
o Referral for Full ID Investigations: Nearly all (98%) of the 3,550 Intake Investigations of
incidents from this Monitoring Period were closed following the completion of the Intake
Investigations, while only 2% of cases were referred for a Full ID Investigation. As shown
in the table above, this is a sharp decline from prior Monitoring Periods. Importantly,
incidents involving Head Strikes and Class A incidents must be referred for Full ID
investigations per the terms of the Consent Judgment, and the Monitoring Team’s review
of Intake Investigations revealed that did not occur consistently or reliably during this
Monitoring Period. Other cases that should have been referred for further investigation
also were not, including cases where the evidence suggested further investigation was
necessary to reach a determination about the appropriateness of the force used.
o Findings of Intake Investigations Not Referred for Full ID Investigations: The table below
depicts the findings of Intake Investigations that were closed as of January 31, 2023 and
were not referred for a Full ID Investigation. Intake Investigation findings included a
statement of whether the incident was “unnecessary,” “excessive,” and “avoidable.” 150
Given the Monitoring Team’s concern about the decline in the detection of and
accountability for misconduct by Intake Investigations discussed above, changes in the
percentage identified as excessive, unnecessary or avoidable are also viewed with
skepticism and concern.

The Department and the Monitoring Team have not finalized an agreed upon definition of these
categories. The definition of these findings and the development of corresponding data is complex,
especially because it requires quantifying subjective information where even slight factual variations can
impact an incident’s categorization. A concrete, shared understanding of what these categories are
intended to capture is necessary to ensure consistent assessment across the board. While efforts were
made in summer 2021 to finalize common definitions, they were never finalized, and has since
languished. The effort has not been reinvigorated given the focus on higher priority items this year. This
categorization process has also not been expanded to Full ID Investigations.
150

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Investigations Status
As of January 31, 2023

Incident Date

Closed Intake Investigations
-

Referred for Full ID

-

Investigations Closed at
Intake

Feb. 3 151 to
June 2020
(10th MP)

July to
Dec. 2020
(11th MP)

Jan. to
June 2021
(12th MP)

July to
Dec. 2021
(13th MP)

Jan. to
June 2022
(14th MP)

July to
Dec. 2022
(15th MP)

2,492

3,272

4,468

3,916

3,352

3,550

411

567

781

634

360

84

2,081

2,700

3,687

3,285

2,992

3,466

Findings of Investigations Closed at Intake
Investigations Closed at Intake

2,081

2,700

3,687

3,285

2,992

3,466

•

Excessive, and/or
Unnecessary, and/or
Avoidable

180 (9%)

477 (18%)

734 (20%)

737 (22%)

531 (18%)

485 (14%)

•

Chemical Agent Violation

164 (8%)

163 (6%)

260 (7%)

324 (10%)

287 (10%)

225 (7%)

Overall Assessment of Intake Investigations
The Monitoring Team reviews thousands of Intake Investigations each Monitoring Period. The
quality and outcomes of Intake Investigations noticeably and dramatically declined during this
Monitoring Period. A critical purpose of the Intake Investigation is to determine whether misconduct
occurred such that it can be addressed immediately or whether the facts of a case warrant additional
scrutiny through a Full ID Investigation. The Intake Investigations completed during this Monitoring
Period simply failed to do so appropriately. Even objective criteria for referring a case for a Full ID
investigation, such as whether the case involved a head strike or a Class A injury, did not occur reliably
or consistently. Most concerningly, Intake Investigations generally failed to identify operational and
security failures that led to an unnecessary use of force. This was particularly true when the Emergency
Services Unit (“ESU”) was involved—it appeared that misconduct by members of ESU teams was often
simply overlooked or ignored. Staff failures in preventing and responding to self-harm events were
similarly overlooked. In short, too many Intake Investigations that ignored objective evidence of
misconduct were closed and failed to refer cases for Full ID Investigations when required.

Incidents beginning February 3, 2020 received Intake Investigations, so those incidents from the early
part of the Tenth Monitoring Period are not included in this data.
151

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Full ID Investigations
When a case merits additional investigation beyond the Intake Investigation, a Full ID
Investigation must be conducted. ID has long struggled to complete Full ID Investigations in a timely
manner, although the number of pending cases has decreased steadily over time. At the end of the current
Monitoring Period, ID had only 360 pending Full ID cases, compared to a pending caseload of over
1,000 cases in the last three Monitoring Periods (n=1,026, 1,194 and 1,182, respectively). This low
caseload is the direct result of two things, both of which are concerning: (1) fewer Full ID referrals from
the Intake Squad, as discussed above and (2) increased closure of Full ID investigations during this
Monitoring Period (907 cases closed compared to 522 closed during last Monitoring Period, an increase
of 74%). Unfortunately, the accelerated case closure rate has occurred at the expense of preserving the
quality of the investigations.
•

Timeliness: ID is required to complete Full ID Investigations within 120 days of an incident. The
table below shows the status of Full ID investigations for all incidents that occurred between
January 2021 and December 2022. Only 16% (n=336) were closed (or remained pending) within
the 120-day timeline, within the remaining 84% outside the required time frame. During this
Monitoring Period, ID closed 907 Full ID Investigations—92% (n=831) of which were closed
outside the required 120-day timeline. Therefore, the Department remains in Non-Compliance
with the timing requirement for Full ID Investigations.
Status of Full ID Investigations
for incidents that occurred between January 2021-December 2022
As of January 15, 2023
Pending less than
Closed within
Closed Beyond
Pending Beyond
120 Days
120 Days
120 Days
120 Days
118
218
1,515
242
6%
10%
72%
12%

•

Total
2,093

Quality of Full ID Investigations: The progress ID investigators made during previous Monitoring
Periods in conducting quality investigations ceased, and in fact, reflected a notable decline.
Previously, the Monitoring Team found the quality of investigations to be mixed: some were
thorough and complete, though some were inadequate. In contrast, the Monitoring Team found
the investigations closed during this Monitoring Period to be often incomplete, inadequate, and
unreasonable. Investigators failed to complete necessary interviews with staff or persons in
custody, did not identify all salient issues, disregarded objective evidence of misconduct,
discredited allegations from people in custody without evidence, and recommended insufficient
employee corrective action. This was a disturbing decline in investigative integrity and quality,
given the slow but steady progress that had been observed in prior Monitoring Periods.

Overall Assessment of Full ID Investigations
In summary, the Department’s level of compliance with the requirements for Full ID
Investigations took a significant step backwards during the current Monitoring Period. Although ID may
have closed a larger number of cases compared to the previous Monitoring Period, nearly all cases were
closed outside the 120-day timeline (perpetuating the Non-Compliance rating in timing), the quality of
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many of the investigations was often substandard, and the findings could easily be discredited. Given the
prominence of Full ID Investigations among the Department’s tools for ensuring accountability for staff
misconduct, this level of performance is extremely concerning.
Referrals for Discipline
Nearly all referrals to the Trials Division for formal discipline for use of force related misconduct
are made following the completion of a Full ID Investigation. This is unsurprising given that the more
egregious and complex cases are referred for Full ID Investigations. That said, with sufficient evidence,
Intake Investigations can also result in formal disciplinary referrals to the Trials Division (although not
likely at the same rate as the completion of a Full ID Investigation). In fact, the number of referrals for
formal discipline from Intake Investigations increased this Monitoring Period (despite the overall
decrease in referrals). While the Monitoring Team’s review of use of force incidents continues to identify
a significant number of cases where referrals for formal discipline appear to be appropriate,
incongruously, in 2022, the overall proportion of cases referred for formal discipline (from any type of
UOF investigation) significantly decreased.
From 2016 to 2021, the average proportion of use of force incidents in which at least one staff
member was referred for formal discipline was 7%. However, in 2022, the proportion of use of force
incidents in which at least one staff member was referred for formal discipline decreased to only 3%.
Some investigations (~200) of 2022 incidents remain pending as of mid-February 2023 when the charges
data below was developed, so some additional referrals for discipline may be forthcoming, but the
resolution of these cases is not expected to alter this proportion significantly. The decline in the
proportion of cases referred for formal discipline was particularly pronounced among cases closed after
May 2022. As noted above, the Monitoring Team has not identified a contemporaneous change in the
pattern and practice of unnecessary and excessive force that would account for a reduction in the number
of referrals. In fact, the number of such referrals typically increases as the quality of investigations
improves and the ability to identify misconduct is more consistent and reliable. The decline in
investigation quality discussed above no doubt contributes to the decline in referrals for formal
discipline.

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ID Staffing
The City is required to ensure that the Department has appropriate resources to conduct timely
and quality investigations. Adequate staffing and appropriate case assignment are critical to conducting
timely, quality investigations. ID’s staffing levels at the end of each year since 2018 are presented in the
table below, along with data from the end of June 2022 to provide for a 6-month comparison to
December 2022. In 2022, the number of civilian and uniform staff serving as investigators decreased by
22 staff, from its high in 2020 (179, versus 157).
ID Staffing Levels
Dec.
Dec.
Position
2018
2019
Executive Supervisors
12
16
1
1
• Deputy Commissioner
0
0
• Associate Commissioner
1
1
• Assistant Commissioner
4
6
• Director/Acting Director
0
0
• Executive Director
6
8
• Deputy Director Investigator (DDI)
Supervisors
30
41
1
1
• Administrative Manager
13
25
• Supervising Investigator
0
0
• Senior Investigator
0
0
• Supervisor ADW
16
15
• Investigator Captain

167

Dec.
2020
15
1
0
1
4
1
8
38
0
26
0
0
12

Dec.
2021
15
1
0
1
4
1
8
36
0
24
0
0
12

June
2022
13
1
0
1
3
0
8
35
0
22
0
0
13

Dec.
2022
15
1
1
2
3
0
8
32
0
21
1
0
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Investigators
• Investigator Civilian
• Investigator Correction Officer
Support Staff
Total

•

148
77
71
12
201

178
89
89
10
245

179
91
88
10
242

158
80
78
9
217

157
83
74
8
213

157
77
80
8
210

Staff Assignments: Outlined below are the staff assignments within the ID Divisions.
Facility Team Staffing & Case Breakdown for Team with UOF
Caseloads
As of January 15, 2023
Number of Assigned Staff
Investigators

Intake Squad

Supervisors 152
12

Full ID

3

10

UPS

0

4

Totals

15

65

PREA Caseload and Compliance

8

40

Intel/Arrest

2

14

Training

1

1

K-9

0

3

Administration and Tracking, Misc.

2

7

Team/Unit

51

Other Teams

o Intake Investigators: A significant number of investigators (n=51) are assigned to the
Intake Squad, enabling them to investigate a large number of use of force incidents in a
timely manner. The fluctuation in the number of UOF incidents means that there will
always be a need to balance resources, but the current complement of Intake Squad
investigators appears to reasonably accommodate the current caseloads.
o Full ID Investigators: As of the end of the current Monitoring Period, there were only 10
investigators assigned to conduct Full ID Investigations (outside of the UPS) compared to
35 in June 2022 and 51 in July 2021. This significant reduction in staff assigned to Full ID
Investigations suggests that ID has reduced the priority of Full ID investigations (as
discussed earlier in this report). Resources appear to have been shifted to PREA
investigations and compliance (40 investigators assigned as of December 2022 vs. 23 in
June 2022), and Intel/Arrest (14 investigators assigned as of December 2022 vs. 9 in June
2022). At the end of December 2022, each Full ID investigator had an average caseload of

Nine DDIs oversee the supervisors of these teams. The DDIs are not included in the count of
supervisors in this chart.

152

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27—the same average caseload of investigators in June 2022 when there were both
significantly more investigators assigned to Full ID investigations and significantly more
Full ID investigations open. Ten investigators dedicated for Full ID investigations is not
sufficient to conduct thorough and timely investigations for all incidents requiring a Full
ID investigation—caseloads were artificially lowered this Monitoring Period due to
insufficient referrals for Full ID and inadequate closures of cases. The Division must be
prepared to re-dedicate resources to conducting Full ID investigations as the referral
process is improved.
o Recruitment: The Department reports that it continues to actively recruit and hire civilian
investigators, and its recruitment efforts appear to consistently bear fruit. ID has received
a significant number of applicants and interviewed 75 candidates for civilian investigator
positions. A total of 31 offers were extended for civilian investigator positions during this
Monitoring Period. Notably, in June 2022, the requirement for investigators to live in the
five boroughs was removed from the job posting, broadening the potential pool of
applicants.
Overall Assessment of ID Staffing
While ID staffing through the end of the Monitoring Period appeared somewhat steady, there was
a mass exodus of investigators in early 2023 (about 25 investigators left the division) is extremely
concerning. Further, the reduction in resources dedicated to conduct Full ID investigations will only
further inhibit the quality and timeliness of those investigations. Recruitment efforts are ongoing,
however, the increased rate of attrition demands that the Department’s recruitment effort must continue
with vigor.
Law Enforcement Referrals
ID is required to promptly refer to the Department of Investigation (“DOI”) any Staff member
whose conduct in a use of force incident appears criminal in nature. The Monitoring Team has
consistently found that while there is significant concern about staff conduct, most staff conduct does not
appear to rise to the level of criminal in nature. This is consistent with the very small number of criminal
prosecutions brought to date. In those cases that do require a referral, ID has promptly made these
referrals. The Department and the relevant law enforcement agencies routinely collaborate and
communicate about the status of cases that are referred for potential prosecution. In the seven years since
the effective date of the Consent Judgment, 117 use of force cases have been referred to DOI or DOI has
taken them over independent of a referral. Of that already small group of UOF cases, only eight cases
have resulted in criminal charges (with another eight still being considered) over the life span of the
Consent Judgment as demonstrated in the chart below.

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Date of Incident
Total
Criminal Charges Brought/
Trial Underway or Complete
Pending Consideration with
Law Enforcement
Returned to ID for
Administrative Processing

2014
&
2015
9

Law Enforcement Referrals
As of March 1, 2023
2016

2017

2018

2019

2020

2021

2022

Total

16

27

19

15

16

7

8

117

0

2

0

2

2

2

0

0

8

7%

0

0

0

0

0

1

2

5

8

7%

9

14

27

17

13

13

5

3

101

86%

As of March 2023, eight cases were pending investigation with law enforcement: two with DOI,
three with the Bronx District Attorney (“DA”), and three with the U.S. Attorney’s Office for the
Southern District of New York (“SDNY”).
Most of the cases considered for criminal prosecution will not be prosecuted: 90% or more of
cases referred for possible criminal prosecution are returned to the Department with no criminal charges.
That said, these cases often represent very concerning conduct that can and must be addressed
administratively. The Monitoring Team continues to find that a small number of cases languish as they
are passed from agency to agency for consideration of potential criminal charges. Typically, no charges
are brought, and, in the meantime, there is no accountability for the misconduct. A lengthy review period
(with no prosecution) only compounds the delay in accountability when it is then returned to the agency.
There has been some overlap in the egregious cases identified by via the Action Plan requirement § F., ¶
2 and cases being considered for criminal prosecution. The Monitoring Team worked with law
enforcement agencies during this Monitoring Period to advise them of the aggressive timelines set for
investigations pursuant to the Action Plan requirement § F., ¶ 2 (“F2”), which sets aggressive timelines
for the investigation and prosecution of egregious cases. Law enforcement agencies took special care to
swiftly evaluate certain cases that were identified for the F2 process and referred those cases back to
DOC for administrative prosecution if criminal charges were not sought.
Use of Force Priority Squad
The Use of Force Priority Squad (“UPS”) is an important management tool to address some of the
most serious and complex use of force cases. Having a dedicated squad for this purpose helps ID to
ensure that these cases obtain the necessary scrutiny and attention. During this Monitoring Period, 15
cases were assigned to UPS and included a variety of egregious incidents including cases in which staff
members were suspended, cases that were returned to ID following an assessment for criminal charges
by law enforcement, and two recommendations from the Monitoring Team.
UPS closed 46 cases during this Monitoring Period, 34 of which (74%) were closed with charges.
Seventeen of the 46 (37%) incidents were closed in under 120 days, 153 with 16 of the 17 cases resulting

This includes nine cases identified as “F2” cases described further in the Compliance Assessment
(Staff Discipline & Accountability) section of the report.
153

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in referral for formal discipline. As of end of the current Monitoring Period, UPS had 13 pending cases,
including one case that was identified for expedited closure pursuant to Action Plan, § F ¶ 2. One small
bright spot in the work of ID this Monitoring Period is that the UPS has successfully closed serious cases
of misconduct close-in-time to the incident via the process identified in the Action Plan, § F ¶ 2
(described in more detail in the Compliance Assessment (Staff Discipline & Accountability) section of
this report).
Conclusion
The decline in quality of Intake Investigations and Full ID investigations during this Monitoring
Period is concerning and has resulted in a Non-Compliance rating. Further, Full ID investigations are still
not completed in a timely manner. It is critical that ID immediately address the issues identified in this
section so that practice is aligned with the requirements of the Consent Judgment and investigations are
conducted with integrity and result in reliable outcomes. To that end, following the close of the
Monitoring Period, the Department has taken important steps to remediate these issues (as discussed
above). The change in ID’s leadership is expected to have a significant impact on altering the direction
and approach of the Division going forward. Further, dedicated leadership by the Associate
Commissioner of ID in conducting use of force investigations is expected to have an immediate impact
on improving the quality of those investigations.
COMPLIANCE RATING

¶ 1. Non-Compliance
¶ 9 (a). Non-Compliance

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•

RISK MANAGEMENT (CONSENT JUDGMENT § X)

X. RISK MANAGEMENT ¶ 1 (EARLY WARNING SYSTEM)
¶ 1. Within 150 days of the Effective Date, in consultation with the Monitor, the Department shall develop and implement an early
warning system (“EWS”) designed to effectively identify as soon as possible Staff Members whose conduct warrants corrective action
as well as systemic policy or training deficiencies. The Department shall use the EWS as a tool for correcting inappropriate staff
conduct before it escalates to more serious misconduct. The EWS shall be subject to the approval of the Monitor.
a.
The EWS shall track performance data on each Staff Member that may serve as predictors of possible future
misconduct.
b.
ICOs and Supervisors of the rank of Assistant Deputy Warden or higher shall have access to the information on the
EWS. ICOs shall review this information on a regular basis with senior Department management to evaluate staff
conduct and the need for any changes to policies or training. The Department, in consultation with the Monitor, shall
develop and implement appropriate interventions and services that will be provided to Staff Members identified
through the EWS.
c.
On an annual basis, the Department shall review the EWS to assess its effectiveness and to implement any necessary
enhancements.

This provision of the Consent Judgment requires the Department to have a system to identify and correct
staff misconduct at an early stage which the Department has elected to do through the Early Intervention,
Support and Supervision (“E.I.S.S.”) Unit. Further, § A, ¶ (3)(c) of the Action Plan requires the expansion of
E.I.S.S. to support any staff on disciplinary probation and supervisors during their probationary period, and
requires that each facility has at least one supervisor responsible for working with the E.I.S.S. Unit to support
the uniform staff that are in the E.I.S.S. program and address any deficiencies in supervision of those staff that
are identified.
Overview of E.I.S.S. Program
The goal of E.I.S.S. is to identify and support staff whose use of force practices would benefit from
additional guidance and mentorship in order to improve practice and minimize the possibility that staff’s
behavior escalates to more serious misconduct. The table below depicts the work of E.I.S.S. between January
2020 and December 2022, the last six Monitoring Periods, and the last column in the table depicts the overall
caseload of the program since its inception in August 2017. Most of the 49 staff selected for monitoring during
the 15th Monitoring Period were identified due to placement on disciplinary probation (n=37) 154, while a small
number of staff were screened and selected for monitoring based on referrals from the Trials Division, ID, or
the individual facilities.

154

As required by § A, ¶ (3)(c) of the Action Plan.

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Overview of E.I.S.S. Program
Jan. to
June 2020
(10th MP)

July to
Dec. 2020
(11th MP)

Jan. to
June 2021
(12th MP)

July to
Dec. 2021
(13th MP)

Jan. to
June 2022
(14th MP)

July to
Dec. 2022
(15th MP)

Program to Date
–
August 2017 to
December 2022

Screening
Staff Screened 155

158

60

82

35

64

53

976

Staff Selected for
Monitoring 156

38

35

53

24

50

49

446

8

35

34

Monitoring
Staff Began
Monitoring Term

50

Staff Actively
Monitored 157

96

106

91

37

80

97

Staff Completed
Monitoring

9

29

17

4

12

13

36

38

315

173

E.I.S.S. Monitoring Program
•

Monitoring Plans: As part of placement in the E.I.S.S. program, monitoring plans are developed for
each staff member by E.I.S.S. staff with input from the staff member. The monitoring plans are designed
to guide and track the staff member’s progress in achieving their goals for improved practice.
Leveraging these monitoring plans as a guide, E.I.S.S. conducted bi-monthly meetings with all staff in
the monitoring program. These monitoring plans are also designed to help guide facility leadership in
their mentorship and discussions with the staff members in the program.

•

Engagement by Facility Leadership: The E.I.S.S. program necessarily requires facility-level mentorship
and guidance to support staff while they conduct their regular duties. The engagement of facility
leadership (in particular the Wardens) has been lacking since the program was developed. E.I.S.S.

The number of staff screened for each Monitoring Period may include some staff who were screened
in prior Monitoring Periods and were re-screened in the identified Monitoring Period. The “Program to
Date” column reflects the total number of individual staff screened. Staff are only counted once in the
“Program to Date” column, even if the staff member was screened in multiple Monitoring Periods.

155

Not all staff selected for monitoring have been enrolled in the program. Certain staff left the
Department before monitoring began. Other staff have not yet been placed on monitoring because they
are on extended leaves of absence (e.g., sick or military leave) or are serving a suspension. Finally,
E.I.S.S. does not initiate a staff’s monitoring term if the staff member has subsequently been placed on a
no-inmate contact post due to the limited opportunity for mentorship and guidance.
156

The total number of Actively Monitored Staff for each Monitoring Period includes all staff who began
monitoring during the period, remained in monitoring throughout the Monitoring Period, completed
monitoring, or had been enrolled in monitoring (but not yet started).

157

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leadership reported it has made renewed efforts to engage the facility leadership in the last year which
has led to more engagement from the Wardens with the staff in the program. Monthly meetings between
E.I.S.S. and the Wardens at each facility continued this Monitoring Period. That said, the Wardens have
many other competing priorities, so their bandwidth to provide individual mentorship to staff in E.I.S.S.
remains limited. Involvement of ADWs assigned to E.I.S.S. is designed to bridge this gap as discussed
further below.
Expansion of E.I.S.S. Under the Action Plan
-

Staff on Disciplinary Probation and Probationary Supervisors

The E.I.S.S. unit continued to expand the monitoring program to include any staff on disciplinary
probation and supervisors during their probationary period as required by the Action Plan. As noted above,
most staff selected for monitoring in the 15th Monitoring Period were due to their status on disciplinary
probation. E.I.S.S. also reported it is beginning to onboard the newly promoted class of ADWs into the program
as required by the Action Plan. After that is complete, E.I.S.S. staff will work to onboard the newly promoted
Captains (promoted in March 2023). E.I.S.S. staff continue to coordinate with various stakeholders in the
agency to gain access to the necessary information on staff backgrounds so that they can obtain a complete
understanding of the staff’s practices prior to placement in E.I.S.S., and to ensure that the monitoring plans are
tailored to address the underlying conduct that may have resulted in the staff’s placement on probation or any
issues raised during the screening of newly promoted staff. The Monitoring Team recommends this
coordination is prioritized and information is shared with E.I.S.S. as efficiently as possible—including materials
which identify concerns raised during the screening process for newly promoted supervisors. As noted in the
assessment of compliance with Consent Judgment § XII., Screening & Assignment of Staff, ¶¶ 1-3
(Promotions) of this report, the Monitoring Team has serious concerns regarding the promotion of certain
ADWs, and E.I.S.S. monitoring will hopefully serve as useful support to these newly appointed supervisors and
elevate their ability to fulfill the mandates of the role.
-

Assignment of ADW Liaisons

During this Monitoring Period, E.I.S.S. also worked to expand the number of uniform staff that can
support the work of the unit. The unit developed a job description and recruited ADWs who will serve as
facility-based liaisons between the E.I.S.S. unit and the uniform staff that are in the E.I.S.S. program. The goal
is that these ADWs will provide on the ground support to those staff members. The Action Plan requires such
facility liaisons at each facility; however, the Monitoring Team has recommended that this program is rolled out
in phases. First, this will allow E.I.S.S. to determine how best this process will work. Further, due to the limited
pool of available ADWs, and the significant need to prioritize the placement of ADWs in the jails to directly
supervise staff and incarcerated individuals, deployment of ADWs to E.I.S.S. has been limited in the near term.
Two ADWs have been selected and appointed as facility liaisons for E.I.S.S. and will work at AMKC
and GRVC. These facilities were selected because those two facilities were identified as having the most staff in
the E.I.S.S. monitoring program that could benefit from additional support. They will receive training from

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E.I.S.S. leadership and help establish procedures to ensure the efficient use of these roles going forward if and
when more ADWs are available. One outstanding issue is to ensure that the ADW liaisons have dedicated space
that is conducive to meeting with the staff in the jails so that the ADWs may be based in the jails and not at
headquarters. GRVC has dedicated space for the ADW liaison, but AMKC has not yet identified space for this
purpose. The Monitoring Team recommends that accommodations be made for the ADW liaison to maximize
the efficacy of this role and provide staff the support they need.
Staffing for E.I.S.S. Unit
While the new ADW positions will add significant support to the E.I.S.S. program, the unit will
ultimately require additional staff and resources as the program expands. The unit currently consists of three
civilian staff and two uniform staff (in prior Monitoring Periods there were four uniform staff supporting the
unit), and two ADW liaisons. The unit currently has three open positions for civilian employees, but progress
towards filling these roles has been on pause as the ADW positions were filled. The Monitoring Team strongly
recommends that recruiting additional civilians to support this work should resume given the current strain on
uniformed resources.
Conclusion
The work of E.I.S.S. continues and is expanding as required under the Action Plan and is in Partial
Compliance with this requirement. The expansion of this division must be appropriately synchronized with the
various other initiatives underway to ensure that resources are adequately allocated. The Monitoring Team
intends to continue to closely collaborate with E.I.S.S. on this process.
COMPLIANCE RATING

¶ 1. Partial Compliance

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•

STAFF DISCIPLINE AND ACCOUNTABILITY (CONSENT JUDGMENT § VIII & REMEDIAL
ORDER § C)

VIII. STAFF DISCIPLINE AND ACCOUNTABILITY ¶ 1
(TIMELY, APPROPRIATE AND MEANINGFUL ACCOUNTABILITY)
REMEDIAL ORDER § C. (TIMELY, APPROPRIATE, AND MEANINGFUL STAFF ACCOUNTABILITY) ¶ 1 (IMMEDIATE
CORRECTIVE ACTION)
VIII. STAFF DISCIPLINE AND ACCOUNTABILITY ¶ 3 (C) (USE OF FORCE VIOLATIONS)
Consent Judgment, § VIII. ¶ 1. The Department shall take all necessary steps to impose appropriate and meaningful discipline, up to and
including termination, for any Staff Member who violates Department policies, procedures, rules, and directives relating to the Use of
Force, including but not limited to the New Use of Force Directive and any policies, procedures, rules, and directives relating to the
reporting and investigation of Use of Force Incidents and video retention (“UOF Violations”).
First Remedial Order, § C. ¶ 1. Immediate Corrective Action. Following a Use of Force Incident, the Department shall determine
whether any involved Staff Member(s) should be subject to immediate corrective action pending the completion of the Use of Force
investigation, which may include counseling or re-training, reassignment to a different position with limited or no contact with
Incarcerated Individuals, placement on administrative leave with pay, or immediate suspension (collectively, “immediate corrective
action”). The Department shall impose immediate corrective action on Staff Members when appropriate and as close in time to the
incident as practicable. The Department shall document and track any immediate corrective action taken, the nature of the initial
corrective action recommended, the nature of the corrective action imposed, the basis for the corrective action, the date the corrective
action is imposed, and the date of the Use of Force Incident resulting in the immediate corrective action. The requirements in this
provision are not intended to alter the rights of Staff or the burden of proof in employee disciplinary proceedings under applicable laws
and regulations.
Consent Judgment, § VIII. ¶ 3. In the event an investigation related to the Use of Force finds that a Staff Member committed a UOF
Violation:
...
c. The Trials Division shall prepare and serve charges that the Trials Division determines are supported by the evidence within a
reasonable period of the date on which it receives a recommendation from the DCID (or a designated Assistant Commissioner)
or a Facility, and shall make best efforts to prepare and serve such charges within 30 days of receiving such recommendation.
The Trials Division shall bring charges unless the Assistant Commissioner of the Trials Division determines that the evidence
does not support the findings of the investigation and no discipline is warranted, or determines that command discipline or
other alternative remedial measures are appropriate instead. If the Assistant Commissioner of the Trials Division declines to
bring charges, he or she shall document the basis for this decision in the Trials Division file and forward the declination to the
Commissioner or designated Deputy Commissioner for review, as well as to the Monitor. The Trials Division shall prosecute
disciplinary cases as expeditiously as possible, under the circumstances.

This compliance assessment evaluates the provision that requires the Department to impose timely,
appropriate, and meaningful accountability for use of force related violations (Consent Judgment § VIII., ¶ 1), the
Department’s use of immediate corrective action (First Remedial Order § C., ¶ 1), as well as the expeditious
prosecution of cases for formal discipline by the Trials Division (Consent Judgment § VIII., ¶3(c) together. This
compliance assessment only covers the Fifteenth Monitoring Period, which covers July through December 2022.
Staff discipline comes in many forms and can be imposed by a variety of different actors within the
Department, at various stages. The Department has made considerable progress in clearing a backlog of

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languishing disciplinary cases but overall, still does not hold staff accountable in a timely manner, which
inherently undermines the meaningfulness of the discipline and ability to impact future behavior.
Accountability
The Department identifies misconduct via Rapid Reviews, ad hoc review of incidents by civilian and
uniform leadership, Intake Investigations (formerly Preliminary Reviews), and through Full ID investigations.
The Department has various structures to respond to misconduct, including: corrective interviews, 5003
counseling, re-training, Command Disciplines (“CD”), suspensions, and placing an individual on modified duty.
PDRs are utilized to address misconduct of probationary staff. For tenured staff, formal discipline is imposed
through the Department’s Trials Division, generally via a Negotiated Plea Agreement (“NPA”). 158
Overview of Accountability: The table below provides an overview of the accountability for use of force related
misconduct imposed between January 1, 2019 and December 31, 2022. Overall, the Department imposed more
use of force related accountability (n=2,772) in 2022 than in any prior year. The combination of corrective
interviews, Command Discipline and formal discipline means that staff are being held accountable more often
when their conduct violates the Use of Force policy. That said, as discussed throughout this section, much of the
accountability is being issued for incidents that occurred in the past (e.g. a year ago or more). Furthermore, as
discussed in detail below, a significant number of Command Disciplines are still not being issued due to
technical/clerical errors. Finally, the Monitoring Team’s review of incidents continues to find an increase in
misconduct that goes undetected by the various investigatory structures. Thus, while many accountability actions
were taken during the current Monitoring Period, additional accountability was also warranted in a significant
number of cases and was not effectuated. A summary of the accountability measures imposed is provided in the
chart below.

A Negotiated Plea Agreement is an agreed upon settlement between the Respondent uniform staff and
the Trials Division attorneys.

158

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Staff Accountability for Use of Force Related Misconduct
Imposed, 2019 to 2022
2019 159

2020

2021

2022

Jan.-June
2022 14th MP

July-Dec. 2022
15th MP

Support and Guidance Provided to Staff
Corrective
interviews and
5003 counseling

2,700 160

1,378 161

3,205

2,532

1,631

901

Corrective
interviews
(resulting from
CDs)

53

32

35

50

22

28

Corrective Action—Command Discipline & Suspensions
CD – Reprimand

156

126

270

298

133

165

CDs (resulting in
1-5 162 days
deducted)

879

673

794

634

285

349

48

80

83

66

36

30

1083

879

1147

998

454

544

Suspensions by
date imposed
Total

Formal Discipline
PDRs

81

49

2

1

0

1

NPAs

220

327

441

1773

888

885

Total

301

376

443

1774

888

886

Total

1384

1255

1342

1430

All Staff Accountability
1590

2772

Counseling that occurred in the Eighth Period was focused on a more holistic assessment of the staff
member’s conduct pursuant to specific standards set by § X (Risk Management), ¶ 2 that has been
subsequently revised. See Eighth Monitor’s Report at pgs. 172-173.

159

The identification of staff for counseling was in transition in the Ninth Monitoring Period as a result of
a recommendation by the Monitoring Team. See Ninth Monitor’s Report at pgs. 194-196.
160

The Department transitioned the process for identifying staff for counseling during this Monitoring
Period. See Tenth Monitor’s Report at pgs. 168 to 170.
161

Beginning in October 2022, CDs could be adjudicated for up to 10 compensatory days, but only a very
small number of CDs (~20 CDs in total) were adjudicated for 5-10 days in November 2022 and
December 2022.
162

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•

Immediate Corrective Action

The need for immediate corrective action is essential for ensuring that blatant misconduct is addressed
swiftly. Rapid Reviews, ad hoc reviews by uniform or civilian leadership through routine assessment of
incidents, and Intake Investigations are responsible for identifying misconduct for immediate corrective action.
Immediate corrective action (suspension, re-assignment, counseling, and Command Disciplines) is a necessary
tool for addressing misconduct because it allows the Department, close-in-time to the incident, to hold staff to a
common standard for utilizing force, particularly when deviations from that standard are immediately obvious
upon the incident’s review. The Department utilized the following immediate corrective actions during this
Monitoring Period:
Immediate Corrective Action Imposed for UOF Related Misconduct
by Incident Date
Jan.-June
2020

July-Dec.
2020

Jan.-June
2021

July-Dec.
2021

Jan.-June
2022

July-Dec.
2022

N/A

1,337

1,509

1,733

1,653

929

CD – Reprimand

37

89

150

120

133

165

CDs (resulting in 1-5 days deducted)

263

410

511

283

285

349

Suspension

38

42

58

25

34

39

Non-Inmate Contact Post or Modified Duty

4

1

3

3

12

4

Suspensions & Non-Inmate Contact Post or
Modified Duty

42

43

55

26

39

43

Grand Total Immediate Action

342

1,879

2,231

2,161

2,042

1,345

Type
Counseling and Corrective Interviews

The Department identifies a significant number of instances that merit immediate corrective action.
Counseling or corrective interviews are the most recommended immediate action response (via Rapid Reviews)
to identified misconduct. This is reasonable as they are an opportunity for supervisors to provide feedback and
guidance, which is a key component of effective and good leadership. A more detailed discussion regarding the
corrective action recommended from Rapid Reviews is discussed in the Compliance Assessment (First Remedial
Order § A., ¶ 1) section of this report. As discussed in previous reports, the quality of a counseling session is
nearly impossible to effectively measure or quantify. Based on the current state of affairs at DOC, and the
Monitoring Team’s overall assessment of supervision in the Department, there remains a dearth of strong and
effective leadership at DOC at the facility-level, which means the quality of the counseling sessions are not
currently expected to be particularly effective. That said, the fact that the Department is identifying staff that
require counseling, and that these meetings are happening, is a critical first step in improving the management of
staff. As noted further below, the use of CDs can and should be expanded, including improvement in ensuring
that CDs are processed as required.

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Finally, the Department’s use of suspension and/or non-inmate contact/modified duty as an immediate
corrective action is critical given the importance of a timely response to misconduct and the otherwise protracted
disciplinary process. Understandably, the Department wants to ensure that the use of suspensions is utilized in
cases where it is merited given it occurs before a full investigation is complete. That said, the presence of
objective evidence (mainly video) does identify certain cases where such a close-in-time response is merited. In
the summer of 2022, the Monitoring Team found that ID’s recommendations for suspensions began to wane. The
Deputy Commissioner of Investigations reported a preference for utilizing Memorandums of Complaint in lieu of
suspensions. It is unclear why ID elected to limit its use of suspensions but given the current level of misconduct
and the need for swift and immediate accountability, this position is concerning (as discussed in more detail in
the Compliance Assessment (Investigations) section of this report). In response to feedback from the Monitoring
Team, the use of suspensions increased towards the end of the Monitoring Period. While the Department’s use of
suspensions began to decline in the summer of 2021 during the staffing crisis, the number of Use of Force related
suspensions began to increase again in 2022. From January to June 2022 (14th Monitoring Period), the
Department suspended 34 staff and from July to December 2022 (15th Monitoring Period) the Department
suspended 39 staff. The number of suspensions in 2022 is now consistent with levels prior to the 2021 staffing
crisis. That said, the Monitoring Team has long noted that given the protracted delays in imposing discipline
suspensions can and must be used in cases with objective evidence of wrongdoing, especially in more egregious
instances. As discussed in the Compliance Assessment (Investigations) section of this report, instances still
remain in which immediate action should have been taken and it was not. Further, the number of individuals
placed on posts in which they do not interface with persons in custody is utilized sporadically (with a slight
increase in the use of this tool in the 14th Monitoring Period in response to feedback from the Monitoring Team).
While the Monitoring Team fully appreciates that placing staff in positions that do not have contact with persons
in custody is a challenging management issue and could create perverse incentives for certain staff, there are
certain staff who are in a position where placement on posts with contact with persons in custody is simply
unreasonable and creates a known risk of harm. To that end, the consideration of placing individuals in noncontact posts should be utilized more frequently given the type of misconduct that continues to be identified by
the Monitoring Team.
•

Command Discipline

A Command Discipline (“CD”) is a significant corrective action that can be imposed at the facility-level
(in addition to counseling). It is a necessary accountability tool because it can be completed closer-in-time to
when an incident occurs (compared to formal discipline) and result in either days deducted, corrective interviews,
or reprimands. Most importantly, a Command Discipline allows facility leadership to directly address misconduct
occurring in their facility and respond to certain staff misconduct in a fair and timely manner. This is a critical
component to the accountability process and necessarily supports the much needed culture change in the jails.

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The Department promulgated a revised Command Discipline Policy in October 2022. 163 The revised
policy expands the potential penalty of a Command Discipline from 5-days to 10 days, provides more specific
penalty guidelines for specific types of violations, and expands the pool of supervisors who may serve as hearing
officers. Under the revised CD Policy, the command now also has 60 days to initiate a CD in CMS, compared
with only 30 days in the previous policy. The goal of this change is to ensure there is sufficient time to process
CDs and minimize dismissals due to processing delays. This additional time balances the need for close in time
accountability while providing some necessary time for processing of CDs. Prior to these revisions, the
Department had filled the limitations and gaps in the CD policy with an initiative in the Trials Division. The
Trials Division created a mechanism to essentially mimic and expand the use of Command Disciplines so it could
more appropriately address certain lower-level misconduct using a Command Discipline via a Negotiated Plea
Agreement (which can impose a sanction of up to five compensatory days) or offering that the imposed discipline
(generally between five and 20 days) will only remain on the staff member’s record for one year 164 instead of five
years. 165 Under the expanded revised Command Discipline Policy, utilizing CDs for those cases that merit it will
reduce the stress on the Trials Division so the focus of the Trials Division can remain on the imposition of formal
discipline for those cases that merit greater scrutiny, focus, and resources to address.
The CD policy revisions are expected to provide a useful path toward increased close-in-time discipline
for lower-level use of force violations. Overall, the Monitoring Team has long supported the use of Command
Discipline to address lower level operational and procedural errors as it is consistent with sound correctional
practice. The revisions to the Command Discipline policy are appropriate and necessary to ensure that the
Department has a practical, effective mechanism to respond to the variety of use of force misconduct. That said,
while the procedures themselves are reasonable, the Department must also adjudicate the CDs appropriately and
reasonably. As demonstrated in the data below, the Department has long struggled with appropriately and reliably
adjudicating CDs, and must fortify the CD process to ensure that recommended CDs are in fact adjudicated and
imposed.
The table below summarizes the results of all CDs referred from Rapid Reviews since 2019 based on an
analysis conducted by NCU. The 15th Monitoring Period was a transition period for CDs. As discussed above, the
CD policy was promulgated in October 2022, but the corresponding updates to CMS did not occur until February
2023 so most CDs processed in the 15th Monitoring Period were processed under the previous policy. For the
Fifteenth Monitoring Period, the overall number of recommended CDs was the second highest number
recommended since the tracking began. In particular, it appears that an increase in the number of recommended

163

As required by the Action Plan § F, ¶ 3.

The case will not be removed from the staff member’s file if during this one-year period, the staff
member is served with new charges on a Use of Force incident occurring after the date of signature on the
Negotiated Plea Agreement.
164

Cases are generally considered for this type of resolution when the proposed discipline is for
approximately 6 to 15 compensatory days and it is the staff member’s first offense.
165

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CDs began in November 2022 after the new CD policy was promulgated. In terms of the status of CDs
recommended in the Fifteenth Monitoring Period, 592 of 1,216 recommended CDs (49% of all referrals) have
been adjudicated and resulted in substantive outcome (e.g. days deducted, a reprimand, a corrective interview, or
a MOC), while 390 (32%) were dismissed or not processed, and 349 (19%) are still pending. As discussed in
more detail below, 270 (22%) cases (this is a subset of the 390 cases discussed in the preceding sentence) were
dismissed due to failures in processing, all of which is in the Department’s control that could have been avoided.
Status and Outcome of Command Disciplines Recommended by Rapid Reviews
As of December 2022 NCU Report
Month of
Incident/Rapid
Review

Total # of CDs
Recommended

Still
Pending in
CMS

Resulted
in 1-5
Days
Deducted

Resulted
in MOC

Resulted in
Reprimand

Resulted
in
Corrective
Interview

Dismissed at
Hearing or
Closed
Administratively
in CMS

Never
Entered
into CMS

Jan. -June 2019
757
5
1%
390 52%
50
7%
66
9%
42
6%
180
24%
15
2%
(8th MP)
July-Dec. 2029
878
2
0%
489 56%
72
8%
90
10%
11
1%
180
21%
26
3%
(9th MP)
Jan. -June 2020
492
3
1%
263 53%
30
6%
37
8%
10
2%
110
22%
39
8%
(10th MP)
July-Dec. 2020
948
12
1%
410 43%
78
8%
89
9%
22
2%
289
30%
43
5%
(11th MP)
Jan. -June 2021
1229
41
3%
511 42% 131 11% 150 12%
15
1%
318
26%
65
5%
(12th MP)
July-Dec. 2021
1126
24
2%
283 25% 150 13% 120 11%
23
2%
426
38%
97
9%
(13th MP)
Jan. -June 2022
907
36
4%
285 31%
58
6%
133 15%
28
3%
282
31%
84
9%
(14th MP)
July-Dec. 2022
1216
234 19% 349 29%
50
4%
165 14%
28
2%
285
23%
105
9%
(15th MP)
Jul-22
152
8
5%
41
27%
6
4%
17
11%
4
3%
54
36%
22
14%
Aug-22
173
12
7%
47
27%
18
10%
27
16%
2
1%
46
27%
21
12%
Sep-22
160
18
11%
48
30%
6
4%
24
15%
6
4%
36
23%
22
14%
Oct-22
176
24
14%
49
28%
5
3%
27
15%
3
2%
60
34%
8
5%
Nov-22
267
66
25%
81
30%
7
3%
39
15%
9
3%
45
17%
20
7%
Dec-22
288
106 37%
83
29%
8
3%
31
11%
4
1%
44
15%
12
4%
*CDs pending more than a year are not tracked in the CD reports analyzed for this chart and therefore may still appear pending although it is likely they
have since been dismissed.

These data highlight a number of issues that must be addressed. First, CDs are not reliably adjudicated.
While the facilities have improved in appropriately recommending CDs for adjudication, about one-third of those
cases are subsequently dismissed. 166 While a dismissal of a CD may be appropriate at times, the high dismissal
rate demonstrates that the process is not working as intended. Of the 390 cases dismissed or not processed during
the current Monitoring Period:
o 31% (n=120) were dismissed for factual reasons including in response to a hearing on the merits, or because
a staff member resigned/retired/was terminated.
o 69% (n=270) were dismissed because of due process violations (meaning the hearing did not occur within
the required timeframes outlined in policy), because of a clerical error which invalidated the CD, or because

It must be noted that given the large proportion of cases still pending, the full number of cases that
may be dismissed from this Monitoring Period is not yet known, but the number of cases dismissed are
expected to increase as these cases are resolved in the system.
166

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the CD was not entered into CMS at all or not drafted within the required timeframe. It is this almost 70%
of dismissals that are of concern to the Monitoring Team because they reflect a lack of proper management
of an essential accountability tool.
Second, it must be noted that those cases that are adjudicated must be scrutinized to ensure the outcome is
reasonable. Facility leadership have long exhibited an over reliance on the use of a reprimand and corrective
interview (on average about 15% of closed CDs are resolved with either a reprimand or corrective interview) or
imposed the lowest possible number of days. While these responses are certainly appropriate in some cases, it
must be reasonable under the circumstances of each case. Improved and more robust oversight of the adjudication
of CDs must occur to ensure that even those cases that are addressed with a CD are appropriate and consistent
with the policy.
The Command Discipline process is a necessary accountability tool, and the appropriate revisions to the
policy reflect a balanced and improved approach to address less serious misconduct at the facility level. Further,
facilities are generally recommending a Command Disciplines appropriately as a corrective action for a violation
identified in the Rapid Reviews. However, CDs must be reliably adjudicated. NCU has consistently audited CDs
for years, and these audits provide valuable information regarding the current status of CD processing. However,
the Department is not effectively analyzing and applying what is learned in these NCU audits to improve the CD
process. Therefore, significant improvement in practice is needed to minimize administrative errors and
management failures in processing CDs. This also includes improved oversight of the determination of CDs. The
Monitoring Team has long recommended that the Department improve its practice and these recommendations
have gone unaddressed.
•

Status of Cases Referred for Formal Discipline

Overall, between November 1, 2015 and December 31, 2022, formal discipline has been imposed on
tenured staff in at least 4,764 cases (involving approximately 2,780 individual staff members). 167 It is important
to note that the number of disciplinary cases relate to individual staff actions versus use of force incidents. For
instance, in 2020, 690 individual cases were referred for discipline from 447 use of force incidents. With respect
to cases related to incidents from 2021, 669 individual cases were referred for discipline from 533 unique use-offorce incidents. For incidents that occurred 2022, 233 individual cases have been referred from 177 unique
incidents, with 799 investigations still pending (about 360 are Full ID investigations in which a referral for
discipline is more likely) which may identify more cases when the investigations are closed. Investigations
remain pending, so more case referrals related to 2022 cases are expected. As discussed in other sections of this
report, the Monitoring Team has found that ID is not referring cases for discipline at the same rate it has in the
past.

The tracking of disciplinary data was not routinely kept until 2017 so additional discipline may have
been imposed between November 1, 2015 and January 2017, but was not formally accounted for.
167

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The table below presents the status of all cases referred for formal discipline (by incident date). These data
illustrate that about 275 cases with incident dates over a year ago (i.e., 2021 or earlier) remain pending, and thus
the opportunity for timely discipline has clearly been lost.
Status of Cases of Disciplinary Cases & Pending Investigations by Date of Incident
As of December 2022,

Total
Individual
Cases
Closed
Cases
Pending
Cases
Unique
UOF
Incidents

2016

2017

2018

2019

2020

2021

2022

Total

471

620

783

1025

690

669

233

4,491

470

99%

612

99%

767

98%

994

97%

662

96%

478

71%

99

42%

4,082

91%

4

1%

8

1%

16

2%

31

3%

28

4%

191

29%

134

58%

409

9%

191

Pending
Invests.

292

0

371

458

606

447

533

177

0

0

0

0

1

799

800

The Trials Division now has the opportunity to address cases closer in time to when the incident occurs.
The cases being referred to Trials are more contemporaneous (and the previous ID backlog has been resolved),
but the speed with which cases are investigated and referred must still be improved. The reduction in the number
of cases pending with Trials is presented in the chart below. As of the end of December 2022, the number of
cases pending has decreased almost 80% from the number pending at the end of 2021. This marks an enormous
accomplishment for the Trials Division in which the number of pending cases has not only decreased for the first
time in years, but is the lowest since June of 2019. This reduction in pending cases is a direct reflection of the
significant number of cases closed in the last year (n=2,163). As discussed in more detail in other sections of this
report, the number of pending cases has also been impacted by a reduction in the number of referrals for
discipline by the Investigation Division.

As of
the last
day
of…
Pending
Cases

June
2018
(6th
MP)

Dec.
2018
(7th
MP)

June
2019
(8th
MP)

146

172

407

Disciplinary Cases Pending
as of December 2022,
Dec.
June
Dec.
2019
2020
2020
(9th
(10th
(11th
MP)
MP)
MP)
633

1,050

1,445

June
2021
(12th
MP)

Dec.
2021
(13th
MP)

June
2022
(14th
MP)

Dec.
2022
(15th
MP)

1,917

1,911

1,129

409

Discipline Imposed
The table below shows the number of disciplinary cases closed by the Department every year since 2017
and the type of disposition. The Trials Division closed more cases in 2022 (n=2,163) than in any other full year
of monitoring and almost as many disciplinary cases closed in than the previous 5 years combined (n= 2,225 for
•

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cases closed in 2017 to 2021). In fact, the number of NPAs imposed in 2022 (n=1,773) is more than the number
of NPAs imposed in the last 4 years combined (n=1,481).

Date of Formal
Closure
Total Cases
Resolved
NPA
Adjudicated/Guilty
Administratively
Filed
Deferred
Prosecution
Not Guilty

Disciplinary Cases Closed by Department
By Date of Ultimate Case Closure
2017

2018

2019

2020

2021

2022

Jan to
Jun.2022

July. To
Dec, 2022

487

513

268

382

575

2,163

1,101

1,062

395
4

81%
1%

483
3

94%
1%

221
0

82%
0%

327
4

86%
1%

450
16

78%
3%

1,773
42

82%
2%

888
21

81%
2%

885
21

83%
2%

68

14%

18

4%

33

12%

31

8%

33

6%

145

7%

60

5%

85

8%

20

4%

7

1%

12

4%

16

4%

75

13%

199

9%

131

12%

68

6%

0

0%

2

0%

2

1%

4

1%

1

0%

4

0%

1

0%

3

0%

Among the 1,773 NPAs imposed during in 2022, 288 (13%) addressed misconduct that occurred within
one year of case closure, 515 (24%) addressed misconduct that occurred between 1 and 2 years prior, 657 (30%)
addressed misconduct that occurred 2 to 3 years prior, and 703 (33%) addressed misconduct that occurred more
than three years before the case was ultimately resolved. Given the presence of a backlog, the ability to address
cases closer in time to the incident is hampered. Accordingly, when the discipline imposed is divorced in time
from the time the misconduct occurred, it detracts from the meaningfulness of the discipline and the ability to
intervene timely and prevent subsequent misconduct. The significant reduction in the number of pending cases
means the Department can improve its ability to address cases closer in time going forward.
Time Between Incident Date and Case Closure or Pending as of December 31, 2022
Closed
Pending
Total
Discipline
Discipline
0 to 1 year from incident date
288 13% 134 33% 422
16%
1 to 2 years from incident date
515 24% 191 47% 706
27%
2 to 3 years from incident date
657 30%
28
7%
685
27%
More than 3 years from incident date
703 33%
56
14% 759
30%
Total
2,163
409
2,572

•

Disciplinary Continuum

It is critical for the Department to have a continuum of disciplinary options because the severity of
misconduct varies, and so that discipline can become progressively more severe for subsequent misconduct by an
individual. As shown in the table below, the Department imposes a broad spectrum of sanctions from Command

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Disciplines of up to a maximum of 5-day penalty, 168 to more significant penalty days via formal discipline, to
termination.
During this Monitoring Period, the discipline imposed via NPA was for lesser compensatory days. For
instance, 40% of cases closed with a sanction of 1 to 9 days compared with 27% in the last Monitoring Period.
Further, a sanction or 30 days or more was utilized in 21% of cases in this Monitoring Period compared with 30%
in the previous Monitoring Period. As demonstrated in the chart below the proportion of sanctions imposed have
fluctuated across the years. Of course, the underlying misconduct must drive the sanction imposed and so these
data does not necessarily mean the discipline is unreasonable. Further, given the need and focus on eliminating
the backlog, some cases may be resolved with lesser sanctions. That said, given the reduction in the number of
pending cases, and the expansion of CD Directive, the frequency with which the Trials Division utilized Lowe
level sanctions and expungement (discussed in more detail below) must be closely scrutinized and presumptively
should be reduced going forward.
With respect to termination of staff for use of force misconduct, more tenured staff have been terminated
this year (n=10) than in the last five years combined (in which 5 staff were terminated between 2017 and 2021).
These terminations occur after a trial and, as discussed in more detail below, this is likely a reflection that the
Report & Recommendations from OATH ALJ’s more closely align with the disciplinary guidelines.

Trials no longer settles a case for an undetermined number of Command Discipline days, which would
require a hearing at the facility for the reasons discussed in the Seventh Monitor’s Report at pgs. 42-44.

168

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Penalty Imposed for UOF Related Misconduct NPAs
Date of Formal Closure

2017

2018

2019

2020

2021

2022

Total
Refer for Command
Discipline 169
1-5 days
6-9 days
10-19 days
20-29 days
30-39 days
40-49 days
50-59 days
60 days +
Demotion
Retirement/Resignation

395

483

221

327

450

1,773

Termination

Jan to
Jun. 2022
1,773

Jul to Dec.
2022
885

71

18%

66

14%

3

1%

79

>1%

4

1%

79

4%

12

1%

67

8%

31
14
62
74
42
27
14
48

8%
4%
16%
19%
11%
7%
4%
12%

147
19
100
58
42
30
4
12

30%
4%
21%
12%
9%
6%
1%
2%

53
6
57
42
21
4
17
11

24%
3%
26%
19%
10%
1%
8%
5%

24%
4%
25%
14%
10%
5%
5%
9%

64
29
109
64
43
53
18
42

14%
6%
24%
15%
10%
11%
4%
9%

12

3%

5

1%

7

3%

438
163
445
158
168
96
80
118
5
23

3%

24

6%

438
163
445
158
168
96
80
118
5
23

25%
9%
25%
9%
9%
5%
5%
7%
6%
1%

189
51
259
95
97
69
40
72
0
4

21%
6%
29%
11%
11%
8%
5%
8%
0%
0%

249
112
186
62
72
27
40
46
5
19

28%
13%
21%
7%
8%
3%
5%
5%
1%
2%

0

1

0

0

4

10

6

4

In order to evaluate the Department’s overall efforts to impose appropriate discipline that it is consistent
with the Disciplinary Guidelines, the Monitoring Team considers: (1) the specific facts of the case (including the
aggravating and mitigating factors, the staff’s prior history, and other circumstances as appropriate), (2) the time
taken to impose discipline (discussed throughout the report), and (3) the proportionality of the sanctions imposed.
In 2022, the Monitoring Team assessed almost 800 of the cases closed with discipline that occurred after
October 27, 2017, to determine whether the discipline imposed was reasonable and appeared consistent with the
Disciplinary Guidelines (note, additional cases were closed in this Monitoring Period that occurred prior to
October 27, 2017, but were not considered as part of this assessment).
Overall, the Monitoring Team has found that the majority of discipline imposed was reasonable (albeit
delayed). In this Monitoring Period, the Monitoring Team evaluated 397 incidents and found that the discipline
imposed was reasonable in about 73% of cases and was questionable for 23% of cases. This is not to say that the
discipline in these cases was blatantly disproportional, but rather that a more severe penalty may have been
appropriate, but mitigating factors may have favored closure of the case with a lower sanction. Finally, about 4%
of the cases reviewed found that the discipline imposed may have been unreasonable. While most of the
discipline was found to be reasonable, it is worth noting the Monitoring Team found a slight increase in the
number of cases in which the closure was questionable and potentially unreasonable. This will be an area of focus
going forward to ensure that this group of cases does not increase further.

As discussed in the Seventh Monitor’s Report (at pgs. 42-44), NPAs referred for CDs were previously
adjudicated at the Facilities after being referred from the Trials Division which was rife with
implementation issues. This problem has been corrected and now the Trials Division will negotiate a
specific number of days (1 to 5) to be imposed and those specific days will be treated as a CD, rather than
an NPA (the main difference is the case remains on the staff member’s record for one year instead of five
years).
169

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•

Discipline Not Imposed

At times, cases referred for discipline may not ultimately result in a sanction imposed either because the
staff member resigns or retires before the prosecution is complete or because the charges are dismissed.
•

Deferred Prosecution: These are cases in which the staff chose to leave the Department with charges
pending and before the case is resolved. Such cases are categorized as “deferred prosecution” because
no final determination has been rendered but the facts suggest the case should not be dismissed. This
disposition has become increasingly common and appears to be related to the large number of staff
who have left the Department in recent years. When this occurs, the Department defers prosecution,
which would then proceed if the staff member were to return to the Department in the future. If the
staff member should return to DOC, then the Department would proceed with prosecuting the case. In
2022, 9% of cases (n=199) were resolved with a deferred prosecution, which is a decrease in the
proportion of cases closed with deferred prosecution in 2021 (when 13% of cases closed with a
deferred prosecution), but an overall increase from the last few years where the proportion of cases
closed with a deferred prosecution was about 4%.

•

Administratively Filed Cases: Administrative filings occur when the Trials Division determines that
the charges cannot be substantiated or pursued (e.g., when the potential misconduct could not be
proven by a preponderance of the evidence, or when a staff member resigns before charges are
served). In other words, these cases are dismissed. During this Monitoring Period, 85 cases were
closed with administrative filings, which represents about 8% of case closures. In 2022, 145 cases
were closed with administrative filings, which represents about 7% of case closures. The Monitoring
Team evaluated all the closing memos for the 145 administratively filed cases. Over half of the cases
were dismissed on various procedural grounds (e.g., the respondent retired or was already terminated,
the MOC was duplicative, or the incorrect staff member was served) and the dismissal of these cases
appeared reasonable. About half of the cases that were dismissed were due to a finding that they could
not be proven beyond a preponderance of the evidence. Of those cases reviewed, a small handful (~5
cases) seemed unreasonable based on the available evidence reviewed by the Monitoring Team.
Overall, the cases closed via administrative filing have an objectively reasonable basis with a few
exceptions and so the Department has maintained Substantial Compliance with this requirement.

Backlog of Pending Cases
The Trials Division was faced with mounting groups of pending cases, at its height in 2021, almost 2,000
cases were pending discipline. As a result, the Third Remedial Order required the Trials Division to first close a
group of 400 priority cases followed by systematically closing out the rest. To facilitate this effort, the
Monitoring Team was required to identify and recommend steps that the City, Department, and OATH should
take to close the cases remaining in the backlog. To that end, the Monitoring Team recommended that the
Department close all pending cases for incidents that had occurred as of December 31, 2020 (“the 2020 backlog”)
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by the end of 2022 (see the Monitor’s June 30, 2023 Report at pgs. 35 to 37). At the time, the 2020 backlog
consisted of 1,100 cases. As of the end of this Monitoring Period, and all but 87 cases had been resolved. The
Trials Division reports that the remaining cases pending could not be resolved because the staff member was on
long term leave or additional time was needed to close the case. As of the filing of this report, only 65 cases of
the 2020 backlog remain pending.
The Trials Division has exerted significant effort and resources to resolve the 2020 backlog, which did not
even seem achievable a year ago. The elimination of the 2020 backlog is an important step to moving towards
imposing timely discipline, but it did not eliminate the entire backlog. There are still hundreds of cases pending
over a year since the incident occurred. To that end, and as required by the Third Remedial Order, the Monitoring
Team has recommended that the cases pending in which the incident occurred between January 1, 2021 to June
30, 2022 must be resolved by July 15, 2023. Closure of this final group of cases will eliminate the current
backlog and permit the Trials Division to truly address cases that have happened closer in time.
Expeditious Prosecution of Cases
The Trials Division coordinates with multiple stakeholders to resolve a case, including the respondent
(and their counsel) as well as OATH (to the extent a pre-trial conference or trial is needed). The Department’s
ability to prosecute cases expeditiously has been of significant concern for years and the slow rate of progress has
resulted in requirements to address the many facets of the disciplinary process through the First Remedial Order
(§ C. ¶¶ 3 to 5), the Third Remedial Order, and now the Action Plan (§ F). For purposes of this analysis, the
Monitoring Team’s timeliness assessment (and data in the tables below) begins after the investigation has been
closed and referred and examines the time required to process a case from when it has been received by the Trials
Division.
The Trials Division improvements of many different practices, policies, and procedures, and influx of
staff, and the retooling of the disciplinary process at OATH has finally begun to bear fruit. It finally appears
achievable for the Trials Division to expeditiously prosecute cases once the final group of backlogged cases has
been eliminated.
Detailed below is a summary of the efforts taken in 2022 by the Trials Division.
•

Closed Cases: The Trials Division closed 2,163 cases in 2022, which is the most closed in a year and
almost as many cases closed in the last 5 years combined. This increase in the number of cases closed has
had a corresponding impact on the size of the Trials backlog. The number of pending cases (n=409) as of
the end of December is down 64% from the end of June (n=1,129, the end of the previous Monitoring
Period).

•

Time to Close Cases: The length of time to case closure—measured from the date the case was referred
from ID—has increased every Monitoring Period since 2019 when the referral of cases from the ID
backlog began and Trials Division’s own backlog began to grow. It is therefore not surprising that in
2022, 61% (n=1,245) of cases were closed more than a year after referral from ID. The proportion of

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cases closed beyond a year (given the magnitude of the backlog) obscures a significant improvement in
the Trials Division’s ability to close cases more quickly from the time of referral. In 2022, the Trials
Division closed 329 cases within 6 months of referral from ID and a total of 725 cases within one year of
referral. The total number of cases closed within a year of referral is the largest number of cases the Trials
Division has closed within a year of referral since the effective date of the Consent Judgment (the second
highest number of cases closed within a year of referral was in 2018 when 428 cases were closed within a
year of referral). While closure of cases within a year of referral is still way too long, the fact that the
Trials Division has been able to increase the number of cases closed in this time period reflects significant
improvement which must be built upon.
Time from Referral to Trials to Complete Closing Memo
2017 to 2022
2017
Cases Closed
0 to 3 months
3 to 6 months
6 to 12 months
1 to 2 years
2 to 3 years
3+ Years
Unknown

•

492
68 14%
64 13%
124 25%
146 30%
70 14%
20
4%
0
0%

2018 170
282
92
54
51
10
9
23

521
54%
18%
10%
10%
2%
2%
4%

2019 171
62
65
89
35
5
6
9

271
23%
24%
33%
13%
2%
2%
3%

2020

2021

2022

387
75 19%
65 17%
121 31%
98 25%
14
4%
2
1%
12
3%

736
40
5%
88 12%
210 29%
284 39%
81 11%
11
1%
22
3%

2,040
155 8%
174 9%
396 19%
781 38%
369 18%
95
5%
70
3%

Jan to
Jun. 2022
1,033
61
6%
84
8%
224 22%
434 42%
160 15%
34
3%
36
3%

Jul to Dec.
2022
1,007
94
9%
90
9%
172
17%
347
34%
209
21%
61
6%
34
3%

Pending Cases: Another way to examine timely prosecution of cases is to examine how long cases have
been pending with the Trials Division. Over 1,000 cases remained opened at the end of the previous 5
Monitoring periods, with many pending for over a year. At the end of the 15th Monitoring Period, the
Department had 409 cases pending with a little over a quarter pending for over a year.

170

Data for 2017 and 2018 was calculated between MOC received date and date closing memo signed.

Data for 2019 and 2020 was calculated between date charges were served and date closing memo
signed.
171

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Cases pending with Trials at the end of the Monitoring Periods
Jan. to
Jan. to
July to
July to
July to
June,
June,
Dec., 2019
Dec., 2020
Dec. 2021
2020
2021
9th MP
10th MP
11th MP
12th MP
13th MP
Pending service of charges
37
6%
42
4%
47
3%
64
3%
84
4%
Pending 120 days or less
186 28% 373 36% 325 22% 420 22% 217 11%
since service of charges
Pending 121 to 180 days
111 17% 115 11% 165 11% 145 8%
64
3%
since service of charges
Pending 181 to 365 days
202 30% 278 26% 467 32% 511 27% 501 26%
since service of charges
Pending 365 days or more
80 12% 219 21% 413 29% 701 37% 930 49%
since service of charges
Pending Final Approvals
by DC of Trials and/or
30
5%
9
1%
15
1%
66
3% 109 6%
Commissioner
Pending with Law
17
3%
14
1%
13
1%
10
1%
6
0%
Enforcement
Total
663
1,050
1,445
1,917
1,911

•

Jan. to
June, 2022

July to
Dec., 2022

14th MP
55
5%

15th MP
36
9%

137

12%

124

30%

70

6%

47

11%

182

16%

77

19%

616

55%

105

26%

66

6%

10

2%

3

0%

10

2%

1,129

409

Initiatives to achieve a prompt agreed-upon resolution of disciplinary cases when appropriate: The
Monitoring Team has long advocated that cases can and should be resolved between the Department and
the staff member (and their representative, if needed) without having to proceed to a trial. As part of this
effort, the number of pre-trial conferences at OATH have increased exponentially (as discussed in more
detail below) so that, if a settlement could not be reached among the Parties, the Parties could address the
cases with an Administrative Law Judge (“ALJ). The increased scheduling of pre-trial conferences
ensures that more cases are addressed among the parties. Additionally, the Department continued to
encourage cases to settle pre-trial and to expedite case closure by 1) addressing certain lower-level
misconduct using a Command Discipline via a Negotiated Plea Agreement (which can impose a sanction
of up to five compensatory days) or 2) offering that the imposed discipline (generally between five and 20
compensatory days) would only remain on the staff member’s record for one year 172 instead of five
years. 173 As the Monitoring Team has previously reported, these two options are reasonable given that the
range of misconduct that is now directed through Trials varies in its severity (compared with historical
practice in which ID was only investigating the most egregious cases and so only cases with egregious
misconduct were referred to the Trials Division). As noted above, given the evolution of the cases
pending and other dynamics (including revisions to the CD policy), the Monitoring Team has

The case will not be removed from the staff member’s file if during this one-year period, the staff
member is served with new charges on a Use of Force incident occurring after the date of signature on the
Negotiated Plea Agreement.
172

Cases are generally considered for this type of resolution when the proposed discipline is for
approximately 6 to 15 compensatory days and it is the staff member’s first offense.
173

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recommended these initiatives be re-evaluated and that reliance on such an approach can be reduced as it
may not be necessary going forward.
Appeals
Over the last year, there has been an increase in the number of appeals, which is not surprising given the
increased number of cases resolved. The Commissioner’s determination (and imposition of discipline as
warranted) is subject to appeal to the Civil Service Commission174 or as an Article 78 proceeding. According to §
3-01 to 3-04 of Title 60 of the Rules of the City of New York, any civil service employee who receives a
determination of guilty and/or a penalty can file an appeal with the Civil Service Commissioner within 20 days of
the date of notice of the final disciplinary action. Upon a timely appeal, DOC has 30 days to submit the complete
record of the disciplinary proceedings after receiving the notice of the appeal. The Civil Service Commission
then reviews the record of the disciplinary proceeding, allows the parties to submit further written arguments, and
can schedule a hearing before issuing a final decision. The Civil Service Commission then issues a written
decision which will affirm, modify, or reverse the determination being appealed. The Civil Service Commission
may, at its discretion, direct the reinstatement of the employee or permit transfer to a vacancy in a similar
position in another division or department, or direct that the employee's name be placed on a preferred list.
As a result of the increased number of appeals, the Trials Division has designated 4 attorneys (one
supervisor and three attorneys) to support appeals as they are made. These four attorneys will maintain other
work within the Division, but, if and when an appeal is made, they will work with the attorney who prosecuted
the case to ensure timely submission of the appeal and provide support and guidance on the case law.
In 2022, 14 staff appealed the Commissioner’s adoption of R&Rs filed in 2022. One staff member has
appealed his termination by the Commissioner (who adopted the ALJ’s R&R following an OATH trial) via an
Article 78 appeal and that case is still pending. Of the 14 appeals brought before the Civil Service Commissioner,
the Civil Service Commission affirmed the determination in 10 cases, 2 cases are pending, 1 case was found to be
moot because of a post-appeal settlement between Commissioner Molina and COBA President Boscio, and 1
case was overturned by the Civil Service Commission.
In the most concerning decision by the Civil Service Commission, the Civil Service Commission
overturned the Commissioner’s adoption of the OATH R&R recommending termination of a staff member and
instead imposed a penalty of 60 compensatory days. In this case, the Civil Service Commission agreed that the
Respondent engaged in unnecessary and excessive force and falsified his involvement in the case, so there is no
dispute about the facts. However, the Commission found that the penalty should be the maximum penalty short of
termination due to mitigating factors including Respondent’s “unblemished employment record over his fourteen-

Pursuant to Section 813 of the New York City Charter, the Civil Service Commission can decide
appeals from permanent civil servants who were subject to disciplinary penalties following proceedings
held pursuant to section 75 of the Civil Service Law.
174

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year tenure as a Correction Officer,” and the fact that neither inmate was seriously injured. Further, the Civil
Service Commission noted that since this case occurred before the effective date of the Disciplinary Guideline,
October 27, 2017, the disciplinary guidelines did not apply in this case.
This determination raised a number of concerning issues. As an initial matter, it appears that another City
agency has undermined the Department’s efforts to take the steps required by the Consent Judgment. Further, this
case sets a concerning precedent regarding the appropriate standard for assessing misconduct going forward. As
the Monitoring Team has long noted, consideration of whether there was a serious injury as a result of the use of
force, particularly one that was inappropriate, unnecessary, or excessive, is an inappropriate standard. 175 The
misconduct must be judged based on the risk of harm. This is particularly true in this case where the staff
member utilized deadly force in a case where it was not merited. See Consent Judgment, § VIII. (Staff Discipline
and Accountability), ¶ 1. Further, whether or not the disciplinary guidelines were in place when the incident
occurred does not absolve the City and Department from implementing a zero tolerance policy for unnecessary
and excessive force, which was in effect at the time this misconduct occurred. See Consent Judgment, § IV. (Use
of Force Policy), ¶ 3(a). Finally, in an egregious case of use of force misconduct, such as this one, the fact that
the individual may not have engaged in misconduct in the past should not preclude the imposition of termination
in this case. That is simply not appropriate.
The Department has filed a motion for reconsideration and the motion is pending with the Court, which
recently sought clarification from the Department on a number of questions. In short, the determination of the
Civil Service Commission raises serious concerns about the impact on the City and Department’s ability to meet
the requirements of the Consent Judgment, Remedial Orders, and the Action Plan.
Conclusions
Consent Judgment § VIII., ¶ 1: The Department has taken many steps to impose appropriate and meaningful
discipline, up to and including termination. While the meaningfulness of the discipline has so far been undercut
by the backlog, the significant steps taken are sufficient to keep the Department out of Non-Compliance and on a

See, Seventh Monitor’s Report at pgs. 156 to 157 (dkt. entry 327) “. . . the emphasis placed on whether
the inmate sustained serious injuries . . . is misguided and fails to consider the potential risk of harm the
staff conduct posed, or the serious pain that may have been inflicted on the inmate(s) but did not result in
serious injury. It is unquestioned that staff actions can and do result in varying degrees of bodily pain with
no visible or identifiable injury, e.g., chokeholds, takedowns, wall slams, OC, painful escort holds, bodily
strikes, etc. However, the risk of serious injury and the needless infliction of pain when bringing an
incident under control is just as concerning as actions resulting in injuries. In fact, the risk of serious
injury as well needless pain are two of the hallmarks of “excessive and unnecessary force” and thus are at
the center of the concerns that gave rise to the Consent Judgment. Not only does this type of behavior
contribute to a destructive culture, the gratuitous infliction of pain is every bit as actionable in class action
lawsuits to address inhumane conditions and in staff disciplinary matters. Accordingly, failure to give
similar weight to these two hallmarks has a direct impact on the Department’s obligations to seek specific
disciplinary sanctions pursuant to § VIII., ¶¶ 2 (c), (d), and to generally impose meaningful discipline for
UOF misconduct violations pursuant to § VIII., ¶ 1.”
175

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path toward substantial compliance. Significant and sustained work is still needed to ultimately achieve
substantial compliance.
First Remedial Order § C., ¶ 1: The Department has a number of avenues to take corrective action and does takes
immediate corrective action. There is room for improvement in identifying cases for immediate action, especially
by ID during the intake investigation. Additionally, it is critical that the Department provide adequate guidance to
staff when misconduct is identified and ensure that Command Disciplines are processed as they should be.
Consent Judgment § VIII., ¶ 3(c): Trials staff continue to be both productive and efficient in addressing the
backlog as the Trials Division has capitalized on the many improvements made to the system over the past two
years. This year, the Trials Division has closed more cases than ever before in less time and generally the
dispositions of cases are reasonable. Overall, this work has demonstrated that the initiatives prescribed by the
Remedial Orders and Actions Plan are effective and progress can be achieved by working with multiple
stakeholders in different roles (e.g. the Department, OATH, staff and their representatives). However, more work
is necessary as cases are still not begin prosecuted as expeditiously as possible.

COMPLIANCE RATING

Consent Judgment § VIII., ¶ 1. Partial Compliance
First Remedial Order, § C., ¶ 1. Partial Compliance
Consent Judgment § VIII., ¶ 3(c)
•
•
•

Substantial Compliance (Charges per the 12th Monitor’s Report)
Substantial Compliance (Administrative Filing)
Partial Compliance (Expeditiously Prosecuting Cases)

REMEDIAL ORDER § C. (TIMELY, APPROPRIATE, AND MEANINGFUL STAFF ACCOUNTABILITY), ¶ 2
(MONITOR RECOMMENDATIONS)
§ C., ¶ 2. Responding to Monitor Recommendations. Upon identification of objective evidence that a Staff Member
violated the New Use of Force Directive, the Monitor may recommend that the Department take immediate corrective
action, expeditiously complete the investigation, and/or otherwise address the violation by expeditiously pursuing
disciplinary proceedings or other appropriate action. Within ten business days of receiving the Monitor’s recommendation,
absent extraordinary circumstances that must be documented, the Department shall: (i) impose immediate corrective action
(if recommended), and/or (ii) provide the Monitoring Team with an expedited timeline for completing the investigation or
otherwise addressing the violation (if recommended), unless the Commissioner (or a designated Assistant Commissioner)
reviews the basis for the Monitor’s recommendation and determines that adopting the recommendation is not appropriate,
and provides a reasonable basis for any such determination in writing to the Monitor.

The First Remedial Order introduced a provision (§ C., ¶ 2) that requires the Department to
respond within 10 business days to any recommendations from the Monitor to take immediate
corrective action, expeditiously complete the investigation, and/or otherwise address the violation by
expeditiously pursuing disciplinary proceedings or other appropriate action. The Action Plan, § F., ¶ 2,
introduced an additional requirement for the Department to expedite egregious cases on specific

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timelines to ensure those cases are closed as quickly as possible. Given these two requirements are
inextricably linked, they are addressed together herein.
Monitor Recommendations for Immediate Action, etc. (Remedial Order § C., ¶ 2)
The Monitoring Team is judicious in the recommendations that it makes to the Department with
regard to immediate action cases and only identifies those cases where immediate action should be
considered and the incident is not yet stale for immediate action to be taken. Given the Monitoring
Team’s role it is simply not often in a position to have contemporaneous information, and so there are
inherent limitations on the scope of misconduct the Monitoring Team may identify and recommend for
consideration of immediate action. For instance, if the Monitoring Team identifies an incident that
warranted immediate corrective action (and none was taken), but the incident occurred many months
prior, a recommendation is not shared because the appropriate window of opportunity for immediate
action has passed. The recommendations shared herein are therefore only a subset of cases where
immediate action was likely warranted but not taken. The Monitoring Team’s overall goal is to
mitigate lost opportunities for immediate action, but this approach is not failsafe.
Between July and December 2022 (the Fifteenth Monitoring Period), a total of 7
recommendations pursuant to § C., ¶ 2 of the First Remedial Order were submitted to the
Department by the Monitoring Team, to take immediate corrective action. 176
•

In 4 of the 7 cases the Department had already filed formal charges against the staff members
and declined to pursue immediate corrective action in light of the pending MOCs. As discussed
in other areas of this report, the Monitoring Team has serious concerns about the Department’s
approach to defer the use of immediate corrective action (when warranted) and instead refer the
case to the Trials Division given the protracted nature of the disciplinary process. The
Monitoring Team continues to strongly recommend the use of immediate corrective action
because certain misconduct must be addressed close-in-time to the incident, which is not
possible under the current disciplinary process.

•

In two cases, the Department imposed immediate corrective action in light of the
recommendation (one suspension and one modified duty).

With respect to recommendations to expedite the completion of investigations pursuant to the First
Remedial Order § C., ¶ 2, as noted in the Monitor’s October 28, 2022 Report at pg. 162, were not a
fruitful avenue to ensuring those cases were addressed quickly. The Monitoring Team therefore now
recommends expedited resolution of cases pursuant to the Action Plan, § F., ¶ 2 (the “F2” process) for
cases that merit expedited completion of investigations or discipline and investigations. Accordingly, no
recommendations were made this Monitoring Period to expedite cases pursuant to the First Remedial
Order § C., ¶ 2.
176

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In one case, the Department concluded no immediate corrective action was warranted, and the
completed investigation concluded that the force was necessary so the investigation was closed
with no corrective action. This case is an example in which the Department not only missed the
opportunity to impose immediate corrective action, but also failed to address the clear
unnecessary and excessive use of force with any corrective action (immediate or otherwise).
The investigation was unreasonable in light of the objective evidence that identified a number
of serious violations. This type of flawed investigation is discussed in more detail in the
Compliance Assessment (Investigations) section of this report.
Expeditious Resolution of Egregious Misconduct (Action Plan § F., ¶ 2)
•

The Action Plan § F., ¶ 2 (“F2”) sets aggressive timelines for the investigation and prosecution
of egregious cases. This requirement went into effect in mid-June 2022. Pursuant to the Action Plan, a
case identified as needing to be resolved in an expedited manner must be resolved as follows:
•

Investigations: The investigation(s) of the matter must be completed within 30 business days of
identification.

•

Referral for Discipline: The case must be processed for discipline — including completion of
the MOC, referred to the Trials Division, charges served on the Respondent, discovery
produced to the Respondent, an offer for resolution must be provided to the Respondent, the
case filing with OATH, and a pre-trial conference must be scheduled within 20 business days of
the closure of the investigation.

•

Adjudication of Discipline: Any and all disciplinary proceedings, including, but not limited to,
convening a pre-trial conference, conducting a trial before OATH, and submission of a Report
and Recommendation from the OATH ALJ must be completed within 35 business days of the
case being filed with OATH.

•

Imposition of Discipline: The Commissioner must impose the final disciplinary action within
15 business days of receiving the Report and Recommendation from OATH.

Between mid-June and February 2023, a total of 31 cases have been identified for expedited
processing as outlined above. These 31 cases cover the conduct of 30 unique staff members, involved
in 23 unique use of force incidents. The Monitoring Team identified 20 of the 31 cases and the
Department identified the other 11. In all cases, ID closed their investigation within the prescribed
timeframes. With respect to the imposition of discipline, the status of the 31 cases as of March 15,
2023, is:
•

25 cases closed with an NPA.
o Discipline ranged from the very low end (relinquishment of 6 compensatory days) to the
highest end (e.g. relinquishment of 60 compensatory days, plus two-year’s probation;
demotion; or irrevocable retirement). Most (14 out of 25) NPAs included 30 or more
compensatory days. Overall, the discipline imposed in these cases was generally
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reasonable. While some of the outcomes were questionable, the fact that the case was
resolved closer in time to the incident ensures that the discipline is more meaningful.
Further, the NPAs on the lower end of the disciplinary range were for staff who while
involved in a serious incident, was not the primary actor and so the resolution is not
inherently unreasonable.
o 20 of these 25 NPAs were finalized within two months of identification as an “F2” case.
This marks significant improvement over the average time to address identified
misconduct prior to the “F2” process being in place. Five cases took longer to prosecute.
In those 5 cases, the cases settled on either the eve of trial or settled following a trial but
before a decision was issued, and in one case the Department could not prosecute the
case until an outside law enforcement agency determined that it did not intend to seek
criminal charges.
•

Two cases are pending with law enforcement and the Department has been advised it cannot
proceed with administrative proceedings at this time.
o The Monitoring Team worked with these outside agencies to ensure these cases are
efficiently evaluated so that if criminal charges are not pursued, the cases are cleared
back to DOC as soon as possible—that work resulted in two other cases being cleared
back to ID during this Monitoring Period which were resolved with NPAs described
above.

•

One case was rendered moot as OATH recommended the individual for termination related to a
separate case that was tried prior to the identification of the F2 case.

•

Two cases are still pending as of March 2023 because they were only recently referred for F2.

•

Finally, one case was Administratively Filed. While charges for other staff involved in the same
incident were pursued via F2 and closed with NPAs (with penalties of 6, 18, 25 and 35
compensatory days), the charges against this staff member were Administratively Filed. In this
particular case, the decision to Administratively File the case was questionable as the evidence
appeared sufficient to sustain charges.

Overall, the F2 process has been fruitful. Cases that require expedited treatment are in fact
being addressed in an expedited manner, especially compared to the protracted processing times that
currently characterize most disciplinary matters. This approach supports the overall goal to resolve
cases closer in time to the incident. As for the overall resolutions, they are generally reasonable and
mark an impressive step towards imposing close-in-time meaningful discipline for the most egregious
incidents.
Conclusion
The impact of these two provisions is mixed. The requirements with respect to § C., ¶ 2 of the
First Remedial Order may not be as fruitful, it has been a backstop to missing some cases requiring
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immediate action. That said, the Department’s overall position to minimize the use of immediate action
is concerning. However, ID did continue to respond to Monitor Recommendations for consideration
for immediate action as required by § C., ¶ 2., and took action in a few examples as noted above.
Regarding Action Plan § F., ¶ 2, this process appears to be working as designed. The Department has
self-identified cases for expedited treatment, and is not relying exclusively on the Monitoring Team,
which is a positive step. It is clear ID, OATH, and the Trials Division are working diligently towards
expediting these cases and ensuring that they are addressed as they should be.
COMPLIANCE RATING

First Remedial Order § C., ¶ 2. Partial Compliance

FIRST REMEDIAL ORDER § C. 4/THIRD REMEDIAL ORDER ¶ 2 (EXPEDITIOUS OATH PROCEEDINGS)
&
FIRST REMEDIAL ORDER § C. (APPLICABILITY OF DISCIPLINARY GUIDELINES TO OATH
PROCEEDINGS), ¶ 5
Third Remedial Order ¶ 2. Increased Number of OATH Pre-Trial Conferences. Paragraph C.4 of the First Remedial Order
shall be modified to increase the minimum number of pre-trial conferences that OATH must conduct each month for
disciplinary cases involving charges related to UOF Violations. Specifically, as of December 15, 2021, Paragraph C.4 shall
be revised to read as follows: “All disciplinary cases before OATH involving charges related to UOF Violations shall
proceed in an expeditious manner. During each month, Defendants shall hold pre-trial conferences before OATH for at least
150 disciplinary cases involving charges related to UOF Violations, absent extraordinary circumstances that must be
documented. If there continues to be delays in conferencing cases despite this calendaring practice, OATH will assign
additional resources to hear these cases. The minimum number of case conferences required to be held each month under
this Paragraph may be reduced if the Monitor makes a written determination, no earlier than one year after the date of this
Order, that disciplinary cases involving UOF Violations can continue to proceed expeditiously with a lower number of
conferences being held each month.” 177
§ C., ¶ 5. Applicability of Disciplinary Guidelines to OATH Proceedings. The Disciplinary Guidelines developed pursuant
to Section VIII, ¶ 2 of the Consent Judgment shall apply to any OATH proceeding relating to the Department’s efforts to
impose discipline for UOF Violations.

When the Department is unable to settle a disciplinary matter directly with the staff member,
the case must be adjudicated. The Office of Administrative Trials and Hearings (“OATH”), an
administrative law court, adjudicates any contested discipline for tenured staff, pursuant to New York
State Civil Service Laws § 75. OATH is designated as the “deputy or other person” to hear disciplinary
matters for the Department of Correction and stands in the shoes of the Commissioner, with the same
powers and constraints as the Commissioner. Accordingly, OATH’s work must comply with Consent
Judgment, Remedial Orders, and Action Plan.

The Action Plan requires a compliance assessment with First Remedial Order § C. (Timely,
Appropriate, and Meaningful Staff Accountability), ¶ 4. However, this provision was modified by the
Third Remedial Order, ¶ 2 so a compliance rating with Third Remedial Order, ¶ 2 is provided instead.
177

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If a case cannot be settled between the respondent and the Department directly, an ALJ
conducts a pre-trial conference in an attempt to facilitate a settlement. If a settlement still cannot be
reached, then a trial is scheduled so an ALJ (and a different ALJ from the one who conducted the pretrial conference) can assess the evidence to evaluate whether or not the staff member has violated
policy. The ALJ then issues a written decision. If the ALJ determines that a violation occurred, the
decision also includes a proposed penalty. The range of penalties that the ALJ may recommend are set
by law and include a reprimand, a fine of up to $100, a suspension without pay of up to (but no more
than) 60 days, demotion in title, or termination. 178 Accordingly, most of the discipline imposed by
DOC (either through settlement or following a trial) is within this same range of penalties. The
Commissioner has the authority to accept the factual findings and penalty recommendation of the ALJ
or to modify them, as appropriate, in order to resolve the case. The Commissioner’s determination (and
imposition of discipline as warranted) is subject to appeal to the Civil Service Commission or as an
Article 78 proceeding.
The Monitoring Team has raised a number of concerns in the past regarding OATH’s practices,
and much progress has been made by OATH to address these concerns. The practices which required
improvement included:
•

a lack of sufficient capacity to manage and convene the number of pre-trial conferences
necessary to address the Department’s caseload,

•

that the pre-trial conferences were not conducted in a manner that facilitated resolution,
that any subsequent proceedings were protracted, and,

•

if a trial was necessary, that the trial was scheduled too far out, was conducted
inefficiently (e.g., a trial requiring multiple days would occur over many months),

•

and the ALJ’s Report and Recommendation took an unreasonably long time to be
issued (e.g., more than a year).

Finally, the Monitoring Team found that the Report and Recommendations issued by the ALJs
as well as guidance provided by ALJ’s during pre-trial conferences suggested that the application of
precedent on current cases had resulted in disciplinary outcomes that were not always proportionate to
staff misconduct and were not consistent with the New Use of Force Directive or the Disciplinary
Guidelines. 179 As discussed in more detail below, progress has been made to address these concerns.

178

New York State Civil Service Laws § 75 (removal and other disciplinary action), ¶ 3.

179

See, for example, Ninth Monitor’s Report at pg. 206.

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The Monitoring Team’s assessment of the work completed by OATH in this Monitoring Period
is outlined below. 180
OATH Pre-Trial Conferences
Over the last few years, the need for pre-trial conferences has increased as staff were unwilling
to settle cases without at least first having a pre-trial conference before OATH. 181 Given the limited
availability of pre-trial conferences at OATH (previously conferences were held only 4 to 6 days per
month), the resolution of cases were often delayed awaiting a pre-trial conference (and any subsequent
OATH proceedings). While the resolution of cases can and should be resolved without the need for
pre-trial conferences, if a pre-trial conference is needed then it should occur promptly. As a result of
the First and Third Remedial Orders, the number of pre-trial conferences increased exponentially, and
OATH is now required to schedule 150 UOF cases for pre-trial conferences a month. OATH now
conducts pre-trial conferences four days a week. The increased availability of pre-trial conferences has
ensured that if the Department is unable to directly settle the case with the staff member, then a pretrial conference will occur promptly in order to facilitate resolution.
In this Monitoring Period, 1,562 disciplinary cases were scheduled for a pre-trial conference.
Of those, 902 of those cases scheduled were related to use of force incidents and therefore OATH met
the requirement of the Third Remedial Order. A chart with the breakdown of UOF related OATH pretrial conferences is provided in Appendix A. As seen for the first time in the last monitoring period, the
number of cases settling before the pre-trial conference has continued to increase. 69% of the cases
(n=621) scheduled for a pre-trial conference were settled before the pre-trial conference occurred.
Another 5% of cases (n=42) settled at the pre-trial conference, meaning 663 of cases scheduled for pretrial conferences were resolved before or during the OATH pre-trial conference. Notably, the number
of cases scheduled for trial has decreased with only 8% (n=74) of cases scheduled for a trial after the
pre-trial conference. This is an important improvement as previously not only were a large portion of
cases scheduled for trial, but they were scheduled to occur a long time after the pre-trial conference,
further delaying a resolution. As discussed in more detail below, of those cases scheduled for trial, only
a few actually end up requiring a trial and most settle before the trial. It is for this reason that
scheduling the trial close in time to the pre-trial conference ensures that resolution is not protracted
simply because there are built-in delays. It is therefore an improvement that fewer cases are being
scheduled for trial given most will settle.

180

This includes the requirements pursuant to Action Plan, § F, ¶ 10.

See Ninth Monitor’s Report at pgs. 205 to 206 (dkt. entry 341), Tenth Monitor’s Report at pgs. 179 to
181 (dkt. entry 360), First Remedial Order Report at pg. 7 (dkt. entry 365), Eleventh Monitor’s Report at
pgs. 99 to 102 and 245 (dkt. entry 368).
181

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One issue the Monitoring Team identified in the scheduling of pre-trial conferences in this
Monitoring Period was an increase in the need for a second pre-trial conference. A second pre-trial
conference may be needed for a number of reasons, some of which are entirely legitimate (e.g. review
of new evidence is necessary, a staff member has an emergency and cannot attend, etc.). However, the
Monitoring Team found that in about 100 cases scheduled for a pre-trial conference (about 11% of
cases scheduled) a second conference was required because either the staff member was not notified
that the conference was scheduled or because the staff member was unavailable (e.g. on vacation, etc.).
The fact that a staff member was not notified or was scheduled to appear when on vacation suggests a
breakdown in internal processing and is generally avoidable.
In response to the Monitoring Team’s findings, the Trials Division reported that some of these
notification issues appeared to be due to poor administration and issues with processing of notices at
the facility. As a result of the Monitoring Team’s feedback, a “point of contact” to the Trials Division
for every facility was appointed to provide a more streamlined and efficient process in serving staff
with notices to appear at the pre-trial conference. The Trials Division reports the point of contact at
each facility establishes more effective communication within the facilities. In particular, the Trials
Division has reported that the point of contact supports service of timely notices. Further, improved
coordination allows for adjustments to the schedule in advance if the staff member is not available on
the date of the conference, for instance, because of a previously approved vacation day or the staff
member is not scheduled to work on the day of the proposed conference. The Monitoring Team intends
to assess the scheduling of pre-trial conferences in the next Monitoring Period to ascertain whether this
approach has reduced these scheduling issues.
Overall, in 2022, OATH scheduled more pre-trial conferences than ever before. Over 3,000
pre-conferences were scheduled for all DOC disciplinary matters (1,891 of them were use of force
related) reflecting a 141% increase in cases scheduled in 2021 (n=1,245 total cases, which was
previously the highest number of pre-trial conferences convened to date).
Trials at OATH
The overall number of use of force trials conducted by OATH has increased in the last two
years since the First and Third Remedial Orders were entered. Given the focus on addressing the more
egregious cases in the backlog, a significant number of trials were conducted in 2021 as those cases
were prioritized. These priority cases were less likely to settle and so a trial was necessary to reach
resolution. While the number of trials in 2022 has decreased (n=16) from the peak in 2021, the number
of trials conducted in 2022 was almost the same number of trials conducted between 2017 and 2020
(n=17) combined.

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Year
2017
2018
2019
2020
2021
2022
Total

Number of UOF Trials Commenced
Total by First Day the
Trial Commenced
8
2
3
4
26
16
59

Previously, trials were not only scheduled far after the pre-trial conference, but often a trial
requiring a few days of hearings could occur over multiple months. In response to various
recommendations from the Monitoring Team, OATH reports that it now schedules any trial for a UOF
related matter within 80 days of the pre-trial conference. On average, all trials that started in 2022
occurred within 80 days of the pre-trial conference. Further, trials are now generally completed within
3 weeks of when they start. The time between a use of force incident and a trial is still incredibly
lengthy given the backlog. For the 16 trials that were convened in 2022, they addressed 25 use of force
incidents that occurred as follows: 1 occurred in 2017, 6 in 2018, 11 in 2019, 4 in 2020, and 3 in 2021.
As discussed throughout this report, protracted discipline will continue to occur until the backlog in the
Trials Division is eliminated and any referrals from ID are provided in a timelier manner.
For the 15 trials that started and were completed in 2022, 182 all but two R&Rs were issued
within 45 days of the end of the trial (one was issued 132 after the final trial date, and the other was
issued 49 days after the final trial date). This is noteworthy because in the past it has taken over a year
for OATH to complete R&Rs in some use of force cases. 183 The progress with respect to UOF cases is
important.
OATH Reports and Recommendations
OATH issued 27 R&Rs related to UOF cases in 2022 (covering trials started in 2021, 2022, and
one that started in 2020). This is the highest number of UOF-related R&Rs issued since 2016. The 27
use of force R&Rs issued in 2022 provided findings and recommended penalties for 30 staff members.
The ALJ found guilt and agreed with the penalty sought by DOC for 15 staff (in one of these cases, the
ALJ found full guilt but did not recommend a specific penalty because the staff member was already
terminated on other grounds). The ALJ suggested different penalties for the other 15 staff. For 3 staff,
the ALJ recommended dismissal of charges and no penalty. For 11 staff, the ALJ dismissed some

The final trial started in 2022 has not been completed. Additional hearing dates are necessary, but the
staff member is out on maternity leave and the trial will be recommenced upon her return to work.
182

For instance, the R&Rs issued for 6 use of force related trials that started in 2021 took at least 6
months to complete following the close of trial. 2 of the 6 R&Rs took over a year to complete.
183

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charges, but issued findings of guilt in others and therefore, recommended a lower penalty than what
DOC sought. For 1 staff, the ALJ found full guilt, but recommended a higher penalty (termination)
than what was sought by DOC (60 days).
The Trials Division sought termination for 15 staff with R&Rs issued in 2022. For 11 of those
15 staff, the ALJ also recommended termination. For the other 4 staff, the ALJ substantiated at least
some of the charges, but recommended suspension days instead of termination. Of those 4 staff, one
resigned by the time the R&R was issued. For the other 3 staff, the Commissioner accepted the
recommended penalties by the ALJ (2 staff received 60 days suspension, and 1 staff received 30 days
suspension). Finally, it is worth noting that for 6 staff, the Commissioner initiated an Action of the
Commissioner whereby he did not accept the proposed recommendation by the ALJs. For 2 of the 6
staff, the Commissioner imposed a penalty higher than the penalty recommended by the ALJ (for one
of these staff, OATH had recommended dismissal of the charges and the commissioner substantiated
the charges and imposed a penalty). For 4 of the 6 staff, the Commissioner imposed a lower penalty
than the ALJ had recommended. 184
The overall improvement in the efficiencies and outcome of R&Rs is reflected in the table
below, which provides a breakdown of the use of force related R&Rs issued since 2016 and the
outcomes. In some cases, an R&R can cover multiple staff members, so we broke down the ALJ’s
findings by staff member in the chart below.
OATH ALJ’s Report & Recommendations by Staff Member
Year
R&R
was
Issued

2016
2017
2018
2019

Total Number of
R&Rs Issued &
Number of Staff

0 R&Rs covering 0
staff
5 R&Rs covering 5
staff
5 R&Rs covering 6
staff
2 R&Rs covering 5
staff

Guilt on some,
but dismissed
Guilt
Guilt
some cases
Agreed with
Imposed More
Imposed less than
DOC’s
Than DOC
what DOC asked
recommendation
Asked
for, but found
some guilt

Acquittal

ALJ
Recommended
Termination

0 staff

0 staff

0 staff

0 staff

0 staff

0 staff

0 staff

4 staff

1 staff

0 staff

1 staff

0 staff

3 staff

2 staff

0 staff

0 staff

0 staff

0 staff

5 staff

0 staff

In one case, the Commissioner elected not to adopt the recommendation of termination and instead a
penalty of 60 days, 1 year probation and an E.I.S.S. referral was imposed. In the three other cases the
Commissioner reduced the penalties as follows – the recommended 42-day penalty was reduced to 28days, a recommended penalty of 40-days was reduced to 30-days and finally a recommended penalty of
12-days was reduced to 7-days.

184

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2020
2021
2022

2 R&Rs covering 4
staff
16 R&Rs covering
20 staff
27 R&Rs covering
30 staff

1 staff

0 staff

3 staff

0 staff

0 staff

15 staff

0 staff

4 staff

1 staff

6 staff

15 staff

1 staff

11 staff

3 staff

12 staff

The table above reflects a sea change, beginning in 2021, in OATH’s work related to use of
force related misconduct. It is clear that the First and Third Remedial Orders have resulted in improved
practices as outlined below:
• Increased Capacity: Beginning in 2021, the number of trials conducted has increased from an
average of 4 trials per year in 2016-2020 to an average of 21 trials per year in 2021/2022.
• Improved Findings: OATH made a finding of guilty for 92% of staff in 2021 and 2022 (n=46
of 50 staff) compared with 60% in 2016 to 2020 (n=12 of 20 staff). There are also fewer
acquittals with only 8% of staff acquitted in 2021 and 2022 (n=4) compared with 40% in 2016
to 2020 (n=8).
• Increased Penalties Imposed: OATH has adopted DOC’s recommended penalty for 60% of
staff in the last two years compared with 10% in 2016 to 2020. Finally, OATH has
recommended termination for 18 staff in the last two years when it was not recommended once
between 2016 and 2020 (when there certainly were cases that would merit such a finding).
Assessment of Disciplinary Guidelines
The Monitoring Team’s general assessment of the R&Rs rendered by ALJ’s during the pre-trial
Conference as well as analysis in the R&Rs demonstrates that there has been improvement in the
application and consideration of the disciplinary guidelines. In subsequent Monitoring Periods, the
Monitoring Team will conduct a more fulsome assessment, including an assessment of all OATH
R&Rs in which the case was dismissed or the recommended sanction differed from the sanction sought
by DOC.
OATH Procedures and Protocols
The road to reforming OATH’s many convoluted, inefficient, and problematic practices and
procedures has taken several years to unravel and unpack. When these issues were initially identified,
there was significant resistance from OATH to revising its practices and procedures — claiming either
that requirements of the Consent Judgment did not apply or that practices could not be changed. It now
appears that the belief that the reforms contemplated were not feasible was misguided. This resistance
has clearly changed, following significant scrutiny and pressure from the Monitoring Team and the
imposition of two Remedial Orders and the Action Plan.

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OATH is an integral part of the Department’s disciplinary process and the improvements
outlined in this report are important and significant. The notable increase in the number of pre-trial
conferences scheduled has supported the overarching goal of eliminating unnecessary delays in case
processing, reducing the backlog of cases, and ultimately resolving more cases. Scheduling and
conducting trials at OATH is also more efficient than it was before and OATH is conducting more
UOF related trials. Further, as discussed in more detail above, if cases are taken to trial, they result in
recommended penalties from the ALJ that are more aligned with the disciplinary guidelines than in the
past. 185 This important evolution of OATH precedent not only impacts the individual case at issue, but
directly impacts the settlement process both before and during any pre-trial conference. Historically,
despite evidence supporting the penalties sought by the Department, OATH often afforded staff
penalties that were less than what would be offered by the Department or inconsistent with the
disciplinary guidelines. As a general matter, this no longer appears to be occurring.
The combined impact of all of these initiatives by OATH is reflected in the Department’s
ability to resolve more disciplinary cases in a shorter period of time. In particular, the increased
number of cases settling before a pre-trial conference leads to more cases bypassing the OATH trial
process. Further, the number of cases in which staff requests a trial has also decreased and appears to
be limited to those cases where more severe sanctions are being sought. Attempts to delay or frustrate
the disciplinary processes by invoking the need for the involvement of OATH is no longer occurring at
the rate it had been, given that the drawn-out process for scheduling a pre-trial conference or
conducting an OATH trial has now been reduced to a more timely process with more meaningful
recommendations for discipline.
While the improvements made to OATH’s procedures and practices are significant, it must be
emphasized that cases requiring the intervention with OATH will still take a long time to resolve. If a
case does not settle and therefore a trial is needed, it will take that case, at a minimum, 3 months to
work its way through the OATH process. This is because a trial is scheduled 80 days after the initial
pre-trial conference, a trial can take upwards of 3 weeks to complete, and then a report and
recommendation is issued 45 days after the record is closed. Further, the Monitoring Team continues to
find that OATH’s flexibility to address cases outside of defined practices is minimal, even in cases
where reasonable accommodations are necessary. While these situations are generally few in number,
OATH remains rigid and wedded to bureaucratic rules with limited-to-no flexibility even when
warranted.
Overall, the Monitoring Team applauds the significant changes at OATH and finds it
encouraging that many of OATH’s entrenched and inefficient practices and procedures are waning.

185

See Eighth Monitor’s Report at pg. 184.

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Nonetheless, more work remains to be done to support the overall goal of ensuring that meaningful
discipline is imposed timely.
Conclusion
First Remedial Order § C., ¶ 4 & Third Remedial Order ¶ 2: The requirement to convene 150 pre-trial
conferences has been met. Proceedings are more efficient than before as subsequent proceedings
(including trials) are now scheduled in a logical and efficient manner. Accordingly, Substantial
Compliance has been achieved with this provision.
First Remedial Order § C., ¶ 5: OATH proceedings appear to be applying the Disciplinary Guidelines
more appropriately than ever before. A more systematic assessment of OATH’s findings is necessary
before substantial compliance can be achieved.
Third Remedial Order ¶ 3: OATH’s procedure and protocols regarding UOF related disciplinary
matters are more efficient than ever before. Further enhancements to the OATH process are needed to
support the overall goal of ensuring that discipline is imposed timely. In particular, the Monitoring
Team recommends that OATH continues to identify efficiencies in its practices to reduce the time to
schedule, conduct, and issue decisions for trials. As part of this effort, OATH must continue to evaluate
its staffing needs to determine whether additional staff are necessary to support the timely resolution of
disciplinary matters.

COMPLIANCE RATING

First Remedial Order § C., ¶ 4. & Third Remedial Order ¶ 2. Substantial
Compliance
First Remedial Order § C., ¶ 5. Partial Compliance
Third Remedial Order ¶ 3. Partial Compliance

VIII. STAFF DISCIPLINE AND ACCOUNTABILITY ¶ 4 (TRIALS DIVISION STAFFING)
¶ 4. The Department shall staff the Trials Division sufficiently to allow for the prosecution of all disciplinary cases as
expeditiously as possible and shall seek funding to hire additional staff if necessary.

This provision requires the City and the Department to ensure the Trials Division has sufficient
staff to expeditiously prosecute all disciplinary cases. The Department has long struggled to have a
sufficient number of staff to support the caseload within the Trials Division. The Action Plan created
specific requirements to hire additional staff and maintain certain staffing levels. As a result, the
number of staff within the Trials Division appreciably increased in this Monitoring Period for the first
time in years. At the end of December 2022 (the end of the Monitoring Period), the Trials Division had
a total of 45 staff, including 6 supervisors and 27 attorneys (including one intern and five attorneys on
loan from other agencies) as identified in the chart below. This staffing complement supported the

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significant amount of work completed in this Monitoring Period, including efforts to essentially
eliminate the 2020 Backlog.
The chart below provides an overview of the staffing for the Trials Division at the end of each
Monitoring Period since the sixth Monitoring Period in June of 2018.

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Trials Division Staffing
June
2018

Dec.
2018

June
2019

Dec.
2019

June
2020

Dec.
2020

June
2021

Dec.
2021

June
2022

Dec.
2022

4

5

5

5

5

5

4

4

5

6

0

0

0

0

0

0

0

0

1

1

0

0

0

0

0

0

0

0

0

1

0

1

1

1

1

1

1

1

1

0

1

1

1

1

1

1

1

1

1

0

3

3

3

3

3

3

2

2

2

4

Administrative Support
- Administrative
Manager
- Executive Coordinator

6

6

6

6

6

6

6

6

5

5

4

4

4

4

4

4

4

4

4

4

1

1

1

1

1

1

1

1

0

0

- Office Manager

1

1

1

1

1

1

1

1

1

1

Attorneys

21

20

20

20

17

18

18

17

19

27

- Agency Attorney
- Agency Attorney
Intern
- Contract Attorney
- Attorneys on Loan
from Other Agencies
Other Support

21

20

20

20

17

16

15

14

17

21

0

0

0

0

0

2

3

3

0

1

0

0

0

0

0

0

0

0

2

0

0

0

0

0

0

0

0

0

0

5

9

8

8

7

8

7

7

7

5

7

- Legal Coordinator

4

4

3

2

2

2

2

2

3

5

- Investigator

3

1

0

0

1

1

1

1

0

0

- Clerical Associate

1

1

1

1

1

1

1

1

1

1

- Program Specialist

1

1

1

1

1

0

0

0

0

0

- Intern

0

1

1

1

1

1

1

1

0

0

- Front Desk Officer
- Community
Coordinator

0

0

1

1

1

1

1

1

1

1

0

0

1

1

1

1

1

1

0

0

0

0

0

0

0

0

0

0

0

0

40

39

39

38

36

36

35

34

34

45

As of…
Supervisors &
Leadership
- Deputy Commissioner
- Associate
Commissioner
- Deputy General
Counsel
- Executive Manager
Director
- Director

- City Research
Scientists
Grand Total

In this Monitoring Period, the Trials Division dedicated certain staff to address closer in time
use of force incidents and appeals as well as assigned more staff to work on medical incompetence

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cases. As required by the Action Plan, 186 in August 2022, the Trials Division created a team dedicated
to prosecuting new UOF disciplinary cases to ensure their expeditious resolution. 187 As of March 2023,
the team has one Director, seven attorneys, and one legal coordinator. It is worth noting that as the
backlog is eliminated more attorneys (beyond those in this group) will be able to focus on more
contemporaneous UOF cases. The Monitoring Team will be evaluating the processing of UOF cases by
this team in future Monitor’s Reports.
The Trials Division has also designated one supervisor and three attorneys to work on appeals
when they arise, given the influx of appeals (especially on UOF cases). These staff will maintain other
responsibilities within the Trials Division given that the number of appeals does not require full-time
dedicated attorneys, but this assignment will ensure that appeals are managed in a timely manner by
individuals with expertise in appeals.
Finally, the staff assigned to the medical incompetence team has also grown and doubled in
size. As of March 2023, the team of attorneys responsible for medical incompetence cases now
includes a director, six attorneys, and two legal coordinators.
The Trials Division staffing complement, and increase in the number of staff, is a welcomed
improvement. The City and Department must remain vigilant in ensuring that the Trials Division
maintains adequate staffing levels, and, at a minimum, those required by the Action Plan, § F, ¶ 1(a).
Even with the significant reduction of the backlog, staffing levels must remain similar to those in
December 2022 (or greater) because the Trials Division caseload is still high and disciplinary cases are
still not being processed in a timely manner. Substantial Compliance will be achieved when the Trials
Division staffing complement is in a position to expeditiously prosecute cases and there are no further
backlog cases within the Trials Division.
COMPLIANCE RATING

¶ 4. Partial Compliance

186

Pursuant to Action Plan, § F, ¶ 5.

187

As required by the Action Plan, § F ¶ 5.

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•

SCREENING & ASSIGNMENT OF STAFF (CONSENT JUDGMENT § XII)

XII. SCREENING & ASSIGNMENT OF STAFF ¶¶ 1-3 (PROMOTIONS)
¶ 1. Prior to promoting any Staff Member to a position of Captain or higher, a Deputy Commissioner shall review that Staff
Member’s history of involvement in Use of Force Incidents, including a review of the
(a) [Use of Force history for the last 5 years]
(b) [Disciplinary history for the last 5 years]
(c) [ID Closing memos for incidents in the last 2 years]
(d) [Results of the review are documented]
¶ 2. DOC shall not promote any Staff Member to a position of Captain or higher if he or she has been found guilty or
pleaded guilty to any violation in satisfaction of the following charges on two or more occasions in the five-year period
immediately preceding consideration for such promotion: (a) excessive, impermissible, or unnecessary Use of Force that
resulted in a Class A or B Use of Force; (b) failure to supervise in connection with a Class A or B Use of Force; (c) false
reporting or false statements in connection with a Class A or B Use of Force; (d) failure to report a Class A or Class B Use
of Force; or (e) conduct unbecoming an Officer in connection with a Class A or Class B Use of Force, subject to the
following exception: the Commissioner or a designated Deputy Commissioner, after reviewing the matter, determines that
exceptional circumstances exist that make such promotion appropriate, and documents the basis for this decision in the
Staff Member’s personnel file, a copy of which shall be sent to the Monitor.
¶ 3. No Staff Member shall be promoted to a position of Captain or higher while he or she is the subject of pending
Department disciplinary charges (whether or not he or she has been suspended) related to the Staff Member’s Use of Force
that resulted in injury to a Staff Member, Inmate, or any other person. In the event disciplinary charges are not ultimately
imposed against the Staff Member, the Staff Member shall be considered for the promotion at that time.

Strong leadership is crucial to the Department’s efforts to reform the agency. The Monitoring
Team continues to emphasize that the staff the Department chooses to promote sends a message about
the leadership’s values, the culture it intends to cultivate and promote, and their behavior sets an
example for Officers. 188 Given the impact that promotion selections have on the overall departmental
culture, the Monitoring Team closely reviews the screening materials and scrutinizes the basis for
promoting staff throughout the Department.
This compliance assessment discusses the overall number of staff promoted since 2017, a
summary of the changes made to the screening policy during this Monitoring Period, assesses whether
the screening materials and the executed promotions complied with the Consent Judgment provisions,
and includes a discussion regarding the overarching concerns with the promotions of ADWs during
this Monitoring Period.

188

As discussed in detail in the Monitoring Team’s Eighth Report (dkt. 332, at pg. 199).

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Overview of Staff Promotions from 2017 to 2022
The Department promoted the following number of Staff to each rank after conducting a
screening:
Captains
ADWs
Deputy Wardens
Wardens
Chiefs

2017
181
4
5
2
3

2018
97
13
3
5
2

2019
0
3
8
1
3

2020
0
35
0
2
0

2021
0
0
1
4
4

2022
0
26
0
0
0

Screening Policy
The Department addresses the requirements of ¶¶ 1 to 3 in Directive 2230, “Pre-Promotional
Assignment Procedures.” Directive 2230 was revised during this Monitoring Period and finalized in
November 2022. The revisions to the policy, originally described in the Monitor’s Third Report, at pgs.
190-192 189, include:
•

More Discretion Regarding the Frequency of Hiring: The Department can now open
application periods whenever the Commissioner or designee identifies a need for
promotions to a Deputy Warden or above. In the past, there were only two or three
application windows each year.

•

Jail Experience Requirement: Eligibility for promotion to Deputy Wardens no longer
requires at least one year working in a jail setting. The Department reports that this
change allowed more ADWs who have not worked in a jail setting (e.g., serving as the
Executive Director of the Classification Unit) for at least one year to be eligible for this
position.

•

“Outstanding” Ranking: A Deputy Warden candidate may now be ranked “outstanding”
in the Performance Appraisal ranking, even if they were found guilty in a disciplinary
proceeding in the past 6 months. Previously, such a history meant they could not be
ranked “outstanding.” The Department reports that this policy change was made
erroneously and was not intended to be updated in the policy.

The Department also made additional revisions to the policy to clarify procedures that were
already in practice, but were not formally documented in the policy. These practices included that: (1)
Captain positions are subject to background investigations (as stated in past Notices of Civil Service
Exams), (2) candidates for Deputy Warden positions are ranked according to a weighted scale by

The Directive was previously revised in the 8th Monitoring Period (see the Monitor’s Eighth Report, at
pg. 198).

189

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DCAS and interviewed by the Department’s Reassignment Board, (3) the rank-ordered list can be
extended beyond a year by the Commissioner in accordance with DCAS processes.
The Department also revised the policy to adjust for the changes to the Department’s leadership
structure and the removal of the Chief positions. The Reassignment and Promotion Boards that
interview candidates for DW and Warden positions used to rotate members, but now the Commissioner
or designee selects the members who are consistently assigned to the Boards. The Department reports
that this change was made because there are now fewer individuals with the ranks required to sit on
these Boards. Additionally, Chiefs used to conduct final reviews of candidates before they were
reviewed and selected by the Commissioner. The Commissioner still conducts the final review and
makes the selections for promotions, but there are no longer Chief reviews.
Generally, the majority of changes to the policy are reasonable. However, two policy changes
are noteworthy. First, the removal of the one-year jail experience requirement for promotion to Deputy
Warden must be evaluated carefully to determine if a candidate without such experience is appropriate
for promotion. While there may be candidates for which this exception is appropriate (e.g., the
Executive Director of the Classification Unit), supervision experience in the jails is a key component in
understanding and assessing the facility operations and practices that underpin this work. Further, the
erroneous removal of the provision regarding the ranking of outstanding candidates should be
reinstated.
Overview of Promotions During the Fifteenth Monitoring Period
The Monitoring Team reviewed the screening documentation for the 35 staff screened for
promotion to ADW during this Monitoring Period. Ultimately, 26 staff were promoted to ADW, while
the other 9 staff were considered, but not promoted. Of the 26 staff who were promoted, the
Monitoring Team’s review identified that 12 staff lacked an objective or sound basis for promotion
based on the screening materials provided, as explained more below. In other words, almost half of the
individuals recently promoted had been identified via the Department’s own screening process as not
suitable for promotion but were promoted anyway. This fact raises significant concerns about the
Department’s selection criteria and decision-making process for promoting staff.
A further review of those screening materials also suggested that PDRs and CDs may not be
reviewed as necessary during the screening process. Two particularly concerning promotions were in
stark contrast with sound promotional practices— one individual who was previously demoted from
the ADW rank in 2021 was again promoted to ADW in 2022, and another individual was promoted
despite not being recommended for promotion by three divisions and a concerning disciplinary history
raised by a fourth division. As noted in the Introduction to this report, some of these problems may
reflect the fact that the Department does not currently have a cadre of high skilled individuals to select
among, rather than a concerted effort to promote subpar candidates. Certainly, the rank of ADW is ripe
for intensive mentoring to help them to develop the skills they will need, and thus the infusion of

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correctional expertise expected through the new Assistant of Commissioners of Operations are
expected to elevate the ADW ranks.
None of the 26 staff promoted were promoted in explicit contravention of the Consent
Judgment requirements. However, specific nuances in the backgrounds of a large segment of those
promoted, and the process by which the promotions decisions were made, suggests that the
Department’s practices are not aligned with the overall goal of selecting people with the most
appropriate attributes. Further work is needed to refine both policy and practice to ensure the
Department is thoroughly considering the results of the screening process when deciding who to
promote.
Assessment of Screening Materials
The screening requirements of the Consent Judgment were developed to guide the
Department’s identification of Supervisors with the proper attributes. In particular, the Consent
Judgment requires the Department to consider a staff member’s use of force and disciplinary history (¶
1(a)-(d)). Further, the Consent Judgment mandates that staff members may not be promoted if they
have guilty findings on certain violations (¶ 2) or pending UOF disciplinary charges (¶ 3). The
promotion process itself is guided by multiple factors, including the screening requirements of this
section of the Consent Judgment, and is depicted in Appendix C: Flowchart of Promotions Process.
Review of Candidates (¶ 1)
The Monitoring Team’s review of the screening materials found that the Department’s
assessment of each candidate satisfied the requirements of the “Review” as defined by ¶ 1. The
screening forms completed for most of these candidates revealed that they did not have extensive use
of force or disciplinary histories that implicated the standards identified in this requirement. The
background for each candidate was reviewed and documented on the screening forms by the relevant
Divisions, with each Division providing recommendations based on holistic assessments that
considered fitness for leadership even beyond the scope of these Consent Judgment provisions. There
was at least some evidence that some staff with PDRs had been reviewed, but it is unclear the extent to
which a candidate’s PDR history is regularly considered during screening. Although the Monitoring
Team’s independent review of PDR histories did not reveal any PDR cases that should have been
identified, but were not, it is not clear that a specific assessment for all PDRs did occur. An important
aspect of assessing a person’s fitness for a leadership position is an evaluation of any potential PDRs
that may have been present in the last 5 years.
The Monitoring Team’s core concern is that the recommendations flowing from the screening
process were too often ignored. A significant number of individuals were not recommended for
promotion by individual or multiple divisions but were promoted anyway and no explanation for the
deviation from the recommendations was provided. The lack of a documented rationale in such cases
raises concerns about oversight and ultimate decision-making. Those selecting the final candidates

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need to adequately consider these reviews and recommendations. Decisions that are at odds with a
recommendation not to promote should be a rare exception and should be justified in writing. Overall,
the reviews completed by the Department demonstrated that the Divisions charged with screening
reviewed the required information, but there were a significant number of deviations from the
Divisions’ recommendations with no accompanying justification or explanation. Accordingly, the
Department is in Partial Compliance with this provision.
Disciplinary History (¶ 2)
staff members may not be promoted if they have guilty findings on certain violations twice
within 5 years unless the Commissioner finds that there are exceptional circumstances that merit
promotion (“2-in-5 assessment”). In the Department’s assessment of the disciplinary history of the 26
staff members promoted to ADW, 23 did not meet this threshold for exclusion. Three staff were
promoted who did meet this threshold, but the Commissioner determined that exceptional
circumstances existed and approved their promotions. The Department documented these exceptional
circumstances in a written memo shared with the Monitoring Team. In all three instances, the
Department reported that the staff members had not received use of force-related charges from the
Investigation Division since 2020 and had “impeccable” attendance records throughout 2020-2021
when COVID-19 brought the Department’s staffing rates to their lowest. Given their backgrounds, the
typical 12-month probationary period was extended to 24-months for these 3 staff. Given that these
exceptional circumstances were documented, as specified in ¶ 2, these 3 promotions meet the
requirements of the Consent Judgment.
The Monitoring Team examined the Department’s 2-in-5 assessment, which must consider
certain violations imposed via a Negotiated Plea Agreements (“NPAs”) within the past 5 years, all
Personnel Determination Reviews (“PDRs”) imposed within the past 5 years, and all relevant
Command Disciplines (“CDs”). As noted above, this examination revealed that the Department may
not be routinely considering PDRs, and may not be considering CDs as part of this assessment. The
Monitoring Team previously raised this concern in 2019 (see the Monitor’s Seventh Report, dkt. 327,
pgs. 174-175) and in response, the Legal Division agreed to assume responsibility for conducting the
2-in-5 assessment and revised the screening form accordingly (see the Monitor’s Eighth Report at pg.
203). However, this approach was never officially documented in policy.
It now appears that the Trials Division has resumed conducting the 2-in-5 assessment, but the
Trials Division only has access to staff records for NPAs, and not for PDRs or CDs. The vast majority
of violations that would meet this threshold would be imposed via an NPA. Given that NPAs are
handled by the Trials Division and NPAs are an important source of formal discipline, it is appropriate
for the Trials Division to consider if the NPA criterion is met. However, PDRs and CDs may also
trigger the 2-in-5 requirement and so they must also be considered. Therefore, a 2-in-5 assessment
conducted solely by the Trials Division is not sufficient. The Monitoring Team recommended that the

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policy be revised to ensure that the 2-in-5 assessment also considers CDs and PDRs and to designate
the Division or position that will be responsible for this component. That said, the Monitoring Team’s
evaluation of available documentation and data did not reveal any promotions during this Monitoring
Period that would have been called into question because of CDs and/or PDRs. Accordingly, the
Department remains in Substantial Compliance with this provision.
Pending Disciplinary Matters (¶ 3)
None of the staff members promoted during this Monitoring Period had pending disciplinary
charges relating to the use of force at the time of promotion. Accordingly, the Department remains in
Substantial Compliance with this provision.
Overarching Concerns Regarding Promotions
As noted in the Overview above, of the 26 staff promoted to ADW, 12 of those ADW
promotions concerned the Monitoring Team, including 11 staff who were not recommended for
promotion by at least one Division who conducted the screening (e.g. Trials and Litigation Division,
Investigation Division, Legal Division, Health Management Division, Equal Employment Office,
Inspector General, Correction Assistance Response for Employees, Early Intervention, Support, and
Supervision Unit) but were promoted anyway. Some staff may not have been recommended for
promotion for reasons beyond those related to the specific requirements of the Consent Judgment.
However, the veracity of the screening process is called into question when such recommendations
appear to be summarily ignored or dismissed. This concern is not new. As the Monitoring Team has
long noted, the Consent Judgment requirements must be considered holistically and if a staff member
is not recommended for promotion based on the screening, then that recommendation should be given
considerable weight (even if it does not meet one of the Consent Judgment triggers) (see Monitoring
Team’s Eighth Report at pg. 201).
Of the 11 individuals who were not recommended for promotion on at least one screening form,
7 staff were not recommended by one Division and 3 staff were not recommended by two Divisions.
These recommendations did not appear to be given due consideration. In one particularly egregious
case, the staff member was not recommended for promotion by three divisions (HMD, EEO, and the
Trials and Litigation Division). Furthermore, while the Legal Division did not explicitly state their
recommendation for this individual, they did note that the person was a named defendant in multiple
lawsuits and was repeatedly disciplined for inefficient performance. Promoting an individual with
objectively documented concerns is in stark contrast with sound promotional practices. None of the
individual records included any explanation for the departure from the stated recommendations not to
promote.
In 2020, the Department reported that it would provide the basis for the decision to promote a
staff member if they had not originally been recommended for promotion. That did not occur during
this Monitoring Period. To create a more durable practice, the Monitoring Team recommended that the

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Pre-Promotional Screening policy be revised to specify that the Department will closely scrutinize any
candidate who is not recommended for promotion by any Division and, if promotion is determined to
be appropriate, the rationale for overriding the recommendations must be documented.
The Monitoring Team identified an additional and particularly egregious promotion that stands
in stark contrast to sound promotional practices. The screening materials indicated that this person was
previously promoted to ADW in 2020, then demoted to Captain in 2021. Following her second
promotion to ADW in December 2022, this individual was again demoted to Captain in February
2023. It is noteworthy that all of the Divisions involved in promotional screening recommended this
individual for promotion to ADW in 2022, suggesting that the substance of the individual’s history was
not carefully considered by any Division.
Conclusion
While the Department’s promotional screening practices include the requirements of the
Consent Judgement (in addition to relevant issues that extend beyond the scope of the Consent
Judgment), the poor assessment of the implications of the information and decision-making in light of
recommendations not to promote are concerning. These findings fall into a long pattern of questionable
promotion decisions reflective of the Department’s longstanding culture of mismanagement. The
Monitoring Team’s concerns about the suitability of candidates reflects the Department’s lack of a
highly skilled cadre of staff from which strong leaders can be selected. While the recent infusion of
outside expertise should strengthen the leadership skills amongst staff of all ranks, the Department
must continue to strengthen the quality of its screening process to ensure they are selecting the most
skilled staff available to lead other staff in the effort to reform and refine staff practice. The majority of
the Monitoring Team’s concerns articulated above were originally discovered and discussed during
Monitoring Periods dating back several years. Despite the Monitoring Team’s feedback and technical
assistance to improve performance in this area, the Monitoring Team believes that improved
procedures must be put in place to screen staff for promotion and the Department must ensure that
appropriate judgment is being utilized when making these decisions. The Monitoring Team
recommends that the Department improve the rigor of its promotion screening and explicitly revises its
Pre-Promotional Screening policy to address the concerns noted above. The Monitoring Team has also
requested that the Department carefully scrutinize the 12 recently promoted staff with concerning
screening information, provide necessary support to these staff while they are in their 1-year
probationary period, and closely review and assess any misconduct (use of force or otherwise) before
their probationary period expires.
COMPLIANCE RATING

¶ 1. Partial Compliance
¶ 2. Substantial Compliance
¶ 3. Substantial Compliance

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•

SAFETY AND SUPERVISION OF INMATES UNDER THE AGE OF 19
(CONSENT JUDGMENT § XV)

XV. SAFETY AND SUPERVISION OF INMATES UNDER THE AGE OF 19 ¶ 1 (PREVENT FIGHT/ASSAULT)
¶ 1. Young Inmates shall be supervised at all times in a manner that protects them from an unreasonable risk of harm. Staff
shall intervene in a manner to prevent Inmate-on-Inmate fights and assaults, and to de-escalate Inmate-on-Inmate
confrontations, as soon as it is practicable and reasonably safe to do so.

The analysis and compliance rating below apply only to the Department’s efforts to achieve
compliance with this provision with respect to 18-year-old incarcerated individuals. The Monitoring
Team will not assess compliance with the Nunez provisions related to 16- and 17-year-olds in this
Monitoring Period pursuant to the Stipulation and Order Regarding 16- and 17-Year-Old Adolescent
Offenders at Horizon Juvenile Center, ¶ 2 (dkt. 503).
The Monitoring Team has been concerned about violence at RNDC, where the majority of
young adults are held, for several years. Previous reports by the Monitoring Team have discussed
RNDC’s serious incidents, management problems and staffing issues (see e.g., Monitor’s March 2022
Report, pgs. 17-21). The Commissioner’s Violence Reduction Plan and RNDC’s de-escalation units,
both implemented in early 2022, are discussed in the Monitoring Team’s June 2022 Report (pgs. 1820).
The continued implementation of the Violence Reduction Plan and the facility’s stable
leadership throughout the current Monitoring Period has led to encouraging decreases in the rates of
violence at RNDC. As discussed in the Security Practices and Indicators section of this report,
RNDC’s rates of use of force, stabbings/slashings and fights decreased slightly in 2022 compared to
prior years. The more pronounced improvements that became evident in the second half of the year
have continued into 2023.
More specifically, the facility has reported consistent practices that have become more aligned
with sound correctional practice including:
•

RNDC was the first facility to implement the various strategies discussed in the Uniform
Staffing Practices section of this report. Interviews with facility leadership confirm close
collaboration with CMU and suggest that once implementation has been solidified, the
new practices will help to remedy the problems with staff management that have
undercut safety and programming for so long.

•

Facility leaders are emphasizing the need for constructive interaction with people in
custody, addressing their concerns about services and attempting to diffuse interpersonal
conflict. While the Warden, DWs and some Supervisors are reportedly skilled in these
areas, these core competencies need to be infused among all staff to continue to increase
safety.

•

The population of each unit is constantly monitored and adjusted to ensure that no one
SRG has a dominant presence, and that people are assigned housing according to their

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classification level. Occasional flare-ups with interpersonal violence remain, but the
frequency of such events has decreased over time.
•

Program counselors and community vendors have been assigned to each housing unit to
reduce idle time and address rehabilitative needs. The Program Division’s quality
assurance efforts to ensure counselors/vendors keep to the published schedule and
deliver content appropriately have great potential to improve practice. The delivery of
daily recreation has improved, but challenges with several recreation spaces being
inoperable remain, keeping this service from being as consistent as it should be.

•

Facility staff have been supplemented with various special teams (e.g., SRT, ESU) to
support searches, movement, and supervision on the housing units. This support is still in
place, but the facility’s security team is beginning to assume these functions.

•

The frequency and thoroughness of searches to detect and confiscate dangerous
contraband have increased. Continued efforts to identify and address the sources of
contraband are needed to stem the flow of dangerous items (particularly weapons and
drugs) into the facility.

The recent period of improved safety is encouraging, and if this type of progress is sustained
over the next Monitoring Period, the Department is on track to move out of Non-Compliance with this
provision. Additional work remains as described above, but these recent changes suggest the
Department is on the right trajectory for the necessary progress.
COMPLIANCE RATING

¶ 1. (18-year-olds) Non-Compliance

XV. SAFETY AND SUPERVISION OF INMATES UNDER THE AGE OF 19 ¶ 12 (DIRECT SUPERVISION)
¶ 12. The Department shall adopt and implement the Direct Supervision Model in all Young Inmate Housing Areas.

The analysis and compliance rating below apply only to the Department’s efforts to achieve
compliance with this provision with respect to 18-year-old incarcerated individuals. The Monitoring
Team will not assess compliance with the Nunez provisions related to 16- and 17-year-olds in this
Monitoring Period pursuant to the Stipulation and Order Regarding 16- and 17-Year-Old Adolescent
Offenders at Horizon Juvenile Center, ¶ 2 (dkt. 503).
The focus in this Monitoring Period has been on the Commissioner’s Violence Reduction Plan
for RNDC. Accordingly, this provision was not monitored during this Monitoring Period and so a
rating is not provided.
COMPLIANCE RATING

¶ 12. (18-year-olds) Not Rated

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XV. SAFETY AND SUPERVISION OF INMATES UNDER THE AGE OF 19 ¶ 17 (CONSISTENT ASSIGNMENT
OF STAFF)
¶ 17. The Department shall adopt and implement a staff assignment system under which a team of Officers and a Supervisor
are consistently assigned to the same Young Inmate Housing Area unit and the same tour, to the extent feasible given leave
schedules and personnel changes.

The analysis and compliance rating below apply only to the Department’s efforts to achieve
compliance with this provision with respect to 18-year-old incarcerated individuals. The Monitoring
Team will not assess compliance with the Nunez provisions related to 16- and 17-year-olds in this
Monitoring Period pursuant to the Stipulation and Order Regarding 16- and 17-Year-Old Adolescent
Offenders at Horizon Juvenile Center, ¶ 2 (dkt. 503).
Meeting the requirements of the Action Plan must precede the Department’s effort to address
the requirements of this provision. In early 2023, RNDC began implementing the Department’s new
roster management strategy that includes both a software package and clearly articulated requirements
for staff assignments to facility posts (see the Uniform Staffing Practices section of this report for more
detail). Coupled with the Department’s efforts to bring staff who are out on leave back to work, this is
an important first step toward being able to meet the requirements of this provision. Once this new
system has been implemented for a period of time, the Monitoring Team will assess RNDC’s progress
toward consistently assigning officers and Captains to the same housing units day-to-day.
COMPLIANCE RATING

¶ 17. (18-year-olds) Non-Compliance

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CONCLUSION
The foregoing report details a great volume of information about the Department’s
progress toward meeting the requirements of the Action Plan, Remedial Orders, and Consent
Judgment. Parts of the report support cautious optimism that progress is being made, but others
provide ample cause for continuing concern about the current state of affairs. Both reactions are
justified and reflect the anticipated uneven pace of reform. Real change has occurred since the
Action Plan was ordered by the Court. The Commissioner and his corps of well-qualified Deputy
and Associate Commissioners have begun to untangle dysfunction so complex and deeply
entrenched that identifying “where to start” required deep investigation and tenacity. The
practice and cultural changes that are being initiated have real potential to move the Department
toward reducing the imminent risk of harm faced by people in custody and staff.
However, this cautious optimism is tempered by the persistently high rates of use of force
and interpersonal violence, particularly the spike in predatory violence in the form of stabbings
and slashings; by the failure to provide people in custody with the most basic services; by the
reversal of progress observed in the Investigation Division; and by the continued use of
questionable, and sometimes abusive, practices at the hands of ESU and the Department’s
inadequate approach to addressing it. There is certainly progress, but there is also continued
cause for alarm.
In the Monitoring Team’s experience with institutional reform, once small changes start
to occur, bigger changes become possible. Further, these initial changes often expose new
problems or bring clarity to the fact that certain problems continue to persist. In that vein, the
work discussed throughout this report highlights that the following issues need priority action:

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•

The Assistant Commissioners of Operations must be on-boarded as quickly as possible
to provide the long-awaited leadership, expertise and hands-on/eyes-on supervision that
the facilities need to truly begin their culture change. This mentorship and support is
acutely necessary starting with the DW, ADW and Captain ranks such that they can
properly motivate, guide and shape the practices of their subordinates. Five Assistant
Commissioners of Operations are scheduled to begin work in April 2023.

•

The Investigations Division must work to reverse course and reinstate past practices that
brought alignment with the requirements of the Consent Judgment.

•

Now that the staff disciplinary process is flowing more steadily, the Department must
attend to the various forms of discipline to ensure that past problems are not recreated. In
particular, the use of Command Discipline to address staff misconduct must be better
managed to ensure that cases are adjudicated on the merits and that the corrective action
is proportional to the severity of the staff’s misconduct.

•

As the level of chaos in certain facilities has begun to recede, the heavy-handed approach
of the Emergency Services Unit (ESU) stands in stark contrast. ESU must be
reconstituted to include leadership that embraces the goals of the Consent Judgment and
that directs its staff to manage crises in ways that reduce harm rather than amplify it. This
includes ensuring that each ESU staff has been assessed for fitness and temperament to
skillfully manage emergency situations.

•

An individual must be appointed to manage the Nunez compliance effort who has a
nuanced understanding of both the jails’ operation and the Consent Judgement so that
priorities, conflicts, obstacles, and consultation with the Monitoring Team can benefit
from a central organizing function.

Following each major section, the Monitoring Team has also listed a set of next steps to
accelerate the progress that the Monitoring Team has begun to witness.

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Immediate Next Steps & Future Reporting
In anticipation of the Court conference on April 27, 2023, the Monitoring Team has
already scheduled a number of meetings with the Parties to discuss the contents of this report and
potential next steps. At least one of these will involve all Parties and the Monitoring Team to
meet and confer. The Monitoring Team will provide a status report to the Court, along with a
proposed agenda for the conference, no later than April 25, 2023 at 12:00 pm (noon).
Finally, with respect to the Monitoring Team’s future reports, the Monitoring Team
respectfully requests a change in the due date for the next report from June 9, 2023 to July 10,
2023. The current schedule contemplates that the next Monitor’s report would be provided just
six weeks after the Monitor’s April 25, 2023 Status Report and the April 27, 2023 court
conference. Revising the schedule is necessary because six weeks is not sufficient time for any
new actions to occur and for the Monitoring Team to collect, analyze, and interpret the
information and data and then report on those efforts. The additional few weeks to prepare the
report will also permit the Monitoring Team to assess a full year of the Action Plan’s
implementation and to make the requisite findings pursuant to Action Plan § G ¶ 6. Under the
current schedule, the Monitoring Team would be limited in its ability to make the requisite
finding pursuant to Action Plan § G ¶ 6. The Monitoring Team submits that this adjustment to
the schedule will still provide the Court and the Parties timely information and four reports from
the Monitoring Team during the first six months of 2023, which is far more frequent reporting
than contemplated under the Consent Judgment (which only requires one report from the
Monitoring Team during this same time period). For these reasons, the Monitoring Team
respectfully requests that the Court revise Action Plan § G, ¶¶ 2 (iv) to require the next
Monitoring Team’s report to be due on July 10, 2023.

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APPENDIX A: ADDITIONAL DATA

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Installation of Cell Doors
The Action Plan requires the installation of new cell doors in order to strengthen the
security hardware of the jails (§ A. ¶ 1(c) imposes a July 2022 deadline to install 75 new doors at
RNDC and § D. ¶ 5 requires the overall installation of doors 950 doors by July 31, 2024). A
discussion regarding the funds allocated for this project, the process for procuring cell doors, and
installation of cell doors in the Department was included in the Monitor’s October 28, 2022
Report at pgs. 74 to 77. It continues to appear that the City and Department have taken all
available steps to maximize the procurement of new cell doors and have taken the necessary
steps to complete the project as efficiently as possible.
The Department is required to install a total of 950 cell doors 190 by July 31, 2024 at
RNDC and AMKC. 191 As shown in the table below, a total of 850 new cell doors were installed
at RNDC between July 2019 and March 31, 2023. The pace of installation accelerated
significantly in 2022, 192 when 300 new cell doors were installed and another 200 were installed
in the first three months of 2023.
RNDC Cell Door Installation—Completed
Date Installation Completed
Number Installed
July to December 2019
50
January to December 2020
100
January to December 2021
200
January to December 2022
300
January to March 31, 2023
200
Total Doors Installed

850

Another 100 cell doors are scheduled to be installed at RNDC by May 2023.

The Monitor’s October 28, 2022 Report incorrectly described the requirement for the installation of
the 950 cell doors at page 76. The Action Plan requires a total of 950 doors must be installed by July 31,
2024. The Monitor’s October 28, 2022 Report incorrectly stated that 950 doors must be installed between
July 2022 and July 2024.
190

191

As required by the Action Plan § D, ¶ 5.

192

This includes the installation of 75 cell doors at RNDC as required by the Action Plan § A, ¶ 1(c).

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Facility Searches & Contraband Recovery
In 2022, DOC conducted a total of 196,738 searches (195,348 completed by the Facility
and 1,390 special searches 193). Through February of this year, DOC has conducted a total of
27,218 searches (27,006 completed by the Facility and 212 special searches 194). These searches
have resulted in the detection and seizure of a significant volume of dangerous contraband, as
shown in the table below. In 2022, the Department seized 35% more drugs, 75% more weapons,
168% more escape-related items, and 30% more “other contraband” than in 2021. Any
successful effort to remove weapons from a facility is obviously positive but the relatively low
rate of return (i.e., contraband seized per searches conducted) and observations of videotaped
footage of search technique and procedure suggests to the Monitoring Team that additional work
to refine practice remains necessary.
Contraband Recovery, 2021-2023 195
2021

2022

Jan.-Feb. 2023

Drugs

1,049

1,421

389

Weapons

3,144

5,507

534

Escape-Related Item

196

525

65

Other

878

1,145

169

Total

5,267

8,598

1,157

This includes searches by the Emergency Services Unit, the Special Search Team, the Canine Use
and/or Tactical Search operations.
193

194

Id.

The calculation of the data for contraband recovery varies depending on the type of contraband that is
recovered. For example, drug contraband is counted by incident, not the actual number of items seized.
For example, if three different types of drugs were recovered in one location, this is counted as a single
seizure. In contrast, when weapons are seized, each item recovered is counted separately. For example, if
three weapons were seized from a single individual, all three items are counted.
195

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Data Regarding Unmanned Posts & Triple Tours
The table below provides the monthly totals and daily averages from January 2021 to
February 2023 of the total uniform staff headcount, unmanned posts (a post in which a staff
member is not assigned), and triple tours. The total number and daily averages of unmanned
posts and triple tours have both decreased since the start of January 2022 and from prior peaks in
2021. On average, there were 44 fewer unstaffed posts per day in February 2023 compared to the
previous peak in January 2022. There were also 25 fewer triple tours on average in February
2023 compared to the previous peak in August 2021.

Month

Average
Headcount
per Day

Average
Unmanned
Posts
per Day

Total
Unmanned
Posts
per Month

Average
Total Triple
Triple Tours
Tours
per Day 196
per Month

January 2021

8,872

0

6

February 2021

8,835

3

91

March 2021

8,777

5

169

April 2021

8,691

4

118

May 2021

8,576

4

109

June 2021

8,475

4

108

July 2021

8,355

15

470

August 2021

8,459

25

764

September 2021

8,335

22

659

October 2021

8,204

6

175

November 2021

8,089

6

174

December 2021

7,778

23

706

January 2022

7,708

59

1825

24

756

February 2022

7,547

23

638

3

90

March 2022

7,457

29

888

1

41

April 2022

7,353

13

385

0

3

May 2022

7,233

31

972

1

33

This column contains data for the number of staff who worked over 3.75 hours of their third tour. This
chart does not contain data for staff who have worked 3.75 hours or less of their third tour.
196

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Average
Headcount
per Day

Average
Unmanned
Posts
per Day

Total
Unmanned
Posts
per Month

June 2022

7,150

27

815

2

67

July 2022

7,138

20

615

2

58

August 2022

7,068

24

735

2

50

September 2022

6,994

22

649

4

105

October 2022

6,905

26

629

2

63

November 2022

6,837

16

486

2

50

December 2022

6,777

13

395

4

115

January 2023

6,700

13

391

1

38

February 2023

6,632

15

419

0

8

Month

v

Average
Total Triple
Triple Tours
Tours
per Day 196
per Month

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Use of Force Involving Unmanned Posts
The table below provides the number and proportion of uses of force involving
“unmanned posts” as identified by the Department, between January and December 2022. These
incidents involve posts to which no staff member was assigned or instances where the assigned
officer left their post without being relieved (collectively “unmanned posts”). The first two
columns list the number of uses of force involving unmanned posts and the proportion of all uses
of force that this number represents. The third and fourth columns identify the number and
proportion of uses of force that involved unmanned posts and were avoidable (as identified by
the Department) specifically due to the lack of staff on post. In other words, had a staff member
been present, these incidents likely could have been avoided. While the number of incidents
involving an unmanned post were relatively small (approximately 4% of all uses of force in
2022), the Department found that over half of these incidents could have been avoided had staff
been present.
Uses of Force involving Unmanned Posts: January-December 2022

Facility

# of Total UOF
Incidents
involving
Unmanned Posts

% of Total UOF
Incidents
involving
Unmanned
Posts 197

AMKC
EMTC
GRVC
NIC
OBCC
RMSC
RNDC
VCBC
TOTAL

99
46
48
6
19
38
50
4
310

1.41%
0.66%
0.69%
0.09%
0.27%
0.54%
0.71%
0.06%
4.43%

# of UOF
Incidents that
UOF incidents
involving
Unmanned Posts
&
Were Avoidable
72
22
19
3
7
17
26
2
168

% of Total UOF
Incidents
involving
Unmanned Posts
&
Were Avoidable
72.73%
47.83%
39.58%
50.00%
36.84%
44.74%
52.00%
50.00%
54.19%

There were 7,004 total actual uses of force in 2022. This number does not include alleged uses of force
because the Department does not provide avoidable reasons for alleged uses of force.
197

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Sick Leave, Medically Monitored/Restricted, and AWOL Data
The tables below provide the monthly averages from January 1, 2019 to March 25, 2023
of the total staff headcount, the average number of staff out sick, the average number of staff on
medically monitored/restricted duty, and the average number of staff who were AWOL. 198 The
Monitoring Team’s assessment of this data is included in the Uniform Staffing Practices section
of this report.
2019
Month

Headcount

Average
Daily
Sick

Average
Daily %
Sick

Average
Daily
MMR3

Average
Daily %
MMR3

January 2019

10577

621

5.87%

459

4.34%

February 2019

10482

616

5.88%

457

4.36%

March 2019

10425

615

5.90%

441

4.23%

April 2019

10128

590

5.83%

466

4.60%

May 2019

10041

544

5.42%

501

4.99%

June 2019

9953

568

5.71%

502

5.04%

July 2019

9859

538

5.46%

496

5.03%

August 2019

10147

555

5.47%

492

4.85%

September 2019

10063

557

5.54%

479

4.76%

October 2019

9980

568

5.69%

473

4.74%

November 2019

9889

571

5.77%

476

4.81%

December 2019

9834

603

6.13%

463

4.71%

2019 Average

10115

579

5.72%

475

4.71%

Average
Daily
AWOL

Average
Daily %
AWOL

The AWOL data is only available for August 1, 2021-January 26, 2022 and April 2022-March 25,
2023.

198

vii

Case 1:11-cv-05845-LTS-JCF Document 517 Filed 04/03/23 Page 234 of 246

2020
Headcount

Average
Daily
Sick

Average
Daily %
Sick

Average
Daily
MMR3

Average
Daily %
MMR3

January 2020

9732

586

6.02%

367

3.77%

February 2020

9625

572

5.94%

388

4.03%

March 2020

9548

1408

14.75%

373

3.91%

April 2020

9481

3059

32.26%

278

2.93%

May 2020

9380

1435

15.30%

375

4.00%

June 2020

9302

807

8.68%

444

4.77%

July 2020

9222

700

7.59%

494

5.36%

August 2020

9183

689

7.50%

548

5.97%

September 2020

9125

694

7.61%

586

6.42%

October 2020

9079

738

8.13%

622

6.85%

November 2020

9004

878

9.75%

546

6.06%

December 2020

8940

1278

14.30%

546

6.11%

2020 Average

9302

1070

11.49%

464

5.02%

Month

Average
Daily
AWOL

Average
Daily %
AWOL

Average
Daily
AWOL

Average
Daily %
AWOL

1.05%

2021
Headcount

Average
Daily
Sick

Average
Daily %
Sick

Average
Daily
MMR3

Average
Daily %
MMR3

January 2021

8872

1393

15.70%

470

5.30%

February 2021

8835

1347

15.25%

589

6.67%

March 2021

8777

1249

14.23%

676

7.70%

April 2021

8691

1412

16.25%

674

7.76%

May 2021

8576

1406

16.39%

674

7.86%

June 2021

8475

1480

17.46%

695

8.20%

July 2021

1488

17.81%

730

8.74%

August 2021

8355
8459

1416

17.27%

9.36%

September 2021

8335

1703

21.07%

767
744

9.21%

90
77

October 2021

8204

1558

19.46%

782

9.77%

30

0.37%

November 2021

8089

1498

19.08%

816

10.39%

42

0.52%

December 2021

7778

1689

21.79%

775

42

2021 Average

8454

1470

17.46%

699

10.00%
8.32%

0.54%
0.68%

Month

viii

56

0.92%

Case 1:11-cv-05845-LTS-JCF Document 517 Filed 04/03/23 Page 235 of 246

2022
Month

Headcount

Average
Daily
Sick

Average
Daily %
Sick

Average
Daily
MMR3

Average
Daily %
MMR3

Average
Daily
AWOL

Average
Daily %
AWOL

January 1-26, 2022

7708

2005

26.01%

685

8.89%

42

0.55%

February 2022

7547

1457

19.31%

713

9.45%

March 2022

7457

1402

18.80%

617

8.27%

April 2022

7353

1255

17.07%

626

8.51%

23

0.31%

May 2022

7233

1074

14.85%

634

8.77%

24

0.34%

June 2022

7150

951

13.30%

624

8.73%

16

0.22%

July 2022

7138

875

12.26%

608

8.52%

19

0.26%

August 2022

7068

831

11.76%

559

7.91%

17

0.24%

September 2022
October 2022

6994
6905

819
798

11.71%
11.56%

535
497

7.65%
7.20%

6
6

0.09%
0.09%

November 2022

6837

793

11.60%

476

6.96%

7

0.09%

December 2022

6777

754

11.13%

452

6.67%

7

0.10%

2022 Average

7181

1085

14.95%

586

8.13%

17

0.23%

Month

Headcount

January 2023
February 2023
March 1-25, 2023

6700
6632
6667

Average
Daily
Sick
692
680
643

2023 Average

6666

672

2023
Average
Daily %
Sick
10.33%
10.25%
9.64%
10.08%

ix

Average
Daily
MMR3
443
421
402

Average
Daily %
MMR3
6.61%
6.35%
6.03%

Average
Daily
AWOL
9
9
11

Average
Daily %
AWOL
0.13%
0.14%
0.16%

422

6.33%

10

0.15%

Case 1:11-cv-05845-LTS-JCF Document 517 Filed 04/03/23 Page 236 of 246

Staff Suspensions
The table below identifies all staff suspensions effectuated between January 1, 2020 and
December 31, 2022. The number of suspensions in 2022 is the highest number of suspensions
over the last three years. Nearly half the suspension in 2022 were due to sick leave. The
Department’s use of suspensions is discussed throughout this report.

Reason
Sick Leave
Conduct
Unbecoming
Use of Force
AWOL
Arrest
Inefficient
Performance
Electronic
Device
NPA
Other
Contraband
Erroneous
Discharge
Abandoned
Post
Total

Jan. to
June
2020
27

Staff Suspensions
January 2020 to December 2022
July to
Jan. to
July to
Total
Dec.
June
Dec.
2020
2020
2021
2021
12
39
48
90

138

Jan. to
Jun
2022
162

July to
Dec.
2022
143

Total
2021

Total
2022
305

32

60

92

44

84

128

44

55

99

36
0
21

42
0
39

78
0
60

52
0
38

30
165
32

82
165
70

36
34
19

30
63
13

66
97
32

25

19

44

24

5

29

16

23

39

4

14

18

2

2

4

5

5

10

5
2
4

5
4
3

10
6
7

3
1
4

3
3
1

6
4
5

8
3
0

9
8
0

17
11
0

5

0

5

0

0

0

2

0

2

0

0

0

0

0

0

0

1

1

161

198

359

216

415

631

329

350

679

x

Case 1:11-cv-05845-LTS-JCF Document 517 Filed 04/03/23 Page 237 of 246

OATH Pre-Trial Conferences
The table below presents the number of use of force related pre-trial conferences that
were scheduled in each Monitoring Period since July 1, 2020 and the results of those
conferences. The Monitoring Team’s assessment of this information is discussed in both the
Staff Accountability section and Compliance Assessment (Staff Discipline & Accountability)
section of this report.

Total
Conf.
Schd.

UOF #
Requir
ed

UOF
# Held

372

225 199

303
100%

670

300

541
100%

575

350

379
100%

1,447

900

989
100%

1,562

900

902
100%

Pre-Trial Conferences Related to UOF Violations
Results of Pre-Trial Conferences for UOF Cases
Settled Settled
On-Going
Another
Preat
Trial Other
Negotiation Conference
OATH OATH
July to December 2020 (11th MP)
0
111
10
44
124
12
0%
37%
3%
15%
41%
4%
January to June 2021 (12th MP)
0
282
4
85
136
33
0%
52%
1%
16%
25%
6%
July to December 2021 (13th MP)
185
87
4
18
58
26
49%
23%
1%
5%
15%
7%
January to June 2022 (14th MP)
612
76
3
174
105
3
62%
8%
0%
18%
11%
0%
July to December 2022 (15th MP)
621
42
0
153
74
0
69%
5%
0%
17%
8%
0%

UOF Matters & Staff
Admin
Filed

# UOF
Incidents

# Staff
Members

2
1%

274

198

1
0%

367

331

1
0%

284

239

16
2%

574

417

12
1%

The Remedial Order requirement came into effect on August 14, 2020 so was applicable for four and a
half months in the Monitoring Period.
199

xi

Case 1:11-cv-05845-LTS-JCF Document 517 Filed 04/03/23 Page 238 of 246

Individuals Who Died While in the Custody of the New York City DOC
The list below identifies the individuals who died (or were granted compassionate
release ) while in DOC custody between November 1, 2015 and March 31, 2023.
200

Date of Death

Name

Date of Death

1/1/2015
1/8/2015
3/8/2015
4/6/2015
5/31/2015
6/10/2015
8/17/2015
10/13/2015
10/14/2015
11/5/2015
12/4/2015

2015
Cruz, Fabian
Lear, Kenneth
Cagliostro, Richard
Nelson, Alvin
Santiago, Richard
Davis, Kenan
Cruz, Yvonne
Sparkes, Randolph
Gonzalez Richard
Blassingame, Fred
Migliozzi, Martin

1/26/2017
3/7/2017
3/8/2017
3/24/2017
8/27/2017
10/19/2017

2017
Johnson, Richard
Cardona, Luis
Bachtobj, Mohamed
Luski, Eli
Henderson, Wayne
Feratovic, Selmin

6/7/2019
6/9/2019
11/23/2019

2019
Cubilette-Polanco, Daniel
Rivera, Jose
Mcclure, Lebarnes

Name

1/17/2016
1/29/2016
2/24/2016
3/14/2016
4/16/2016
4/18/2016
5/19/2016
5/27/2016
6/3/2016
6/10/2016
8/7/2016
8/17/2016
8/26/2016
12/14/2016
12/28/2016

2016
Marrero, Maria
Perez-Rios, Angel
Adedji, Omole
Polanco- Munoz, Jairo
Bryant, Kareen
Zhang, Zhi
Ruiz, Kenny
Deshields, Michael
Tirado, Carlos
Jones, Clarence
Quiles, Manuel
Acosta, Martin
Webb, Davis
Serrano, Mark
Castelle, Eugene

1/4/2018
1/30/2018
3/4/2018
7/9/2018
8/27/2018
9/18/2018
10/1/2018
11/4/2018

2018
Foster, Joseph
Swanson, Grant
Haynes, Russell
Holloway, Casey
McPeck, David
Sanchez, Sebastian
Johnson Jr., Maurice
McClain, Chiki

This list only includes individuals who were compassionately released in 2021 and 2022. The
Monitoring Team does not have information about whether individuals were compassionately released
prior to their death before January 1, 2021.
200

xii

Case 1:11-cv-05845-LTS-JCF Document 517 Filed 04/03/23 Page 239 of 246

Date of Death

Name

4/5/2020
4/5/2020
4/11/2020
4/16/2020
4/23/2020
5/22/2020
5/28/2020
6/21/2020
10/9/2020
11/23/2020
11/26/2020

2020
Jones, Arniel
Tyson, Michael
Ance, Walter
Branch, Milton
Delrosario Kevin
Kang, Scott
Granados, Junior
Rodriguez, Hector
Cruz, Christopher
Wilson, Ryan
Skervchak, Esther

2/27/2022
3/17/2022
3/18/2022
5/7/2022
5/18/2022
5/28/2022
6/18/2022
6/20/2022
6/21/2022
7/11/2022
7/15/2022
8/15/2022
8/30/2022
9/14/2022
9/20/2022
9/22/2022
10/22/2022
10/31/2022
12/11/2022

2022
Youngblood, Tarz
Pagan, George
Diaz, Herman
Carter, Dashawn
Yehudah, Mary
Sullivan, Emanuel
Bradley, Antonio
Carrasquillo, Anibal
Drye, Albert
Muhammad, Elijah
Lopez, Michael
Cruciani, Ricardo
Nieves, Michael
Bryan, Kevin
Acevedo, Gregory
Pondexter, Robert
Tavira, Erick
Garcia, Gilberto
Mejias, Edgardo

Date of Death
1/23/2021
3/2/2021
3/22/2021
4/19/2021
5/1/2021
6/10/2021
6/30/2021
8/10/2021
8/30/2021
9/7/2021
9/19/2021
9/22/2021
10/15/2021
10/18/2021
12/10/2021
12/14/2021
02/04/2023

xiii

Name

2021
Diaz-Guzman, Wilson
Comacho, Carlo Tomas
Velasco, Javier
Braunson III, Thomas
Blake, Richard
Mejia, Jose
Jackson, Robert
Rodriguez, Brandon
Guallpa, Segundo
Johnson, Esias
Isaabdul, Karim
Khadu, Stephen
Mercado, Victor
Scott, Anthony
Boatwright, Malcolm
Brown, William
2023
Pines, Mavin

Case 1:11-cv-05845-LTS-JCF Document 517 Filed 04/03/23 Page 240 of 246

APPENDIX B:
DEFINITIONS

Case 1:11-cv-05845-LTS-JCF Document 517 Filed 04/03/23 Page 241 of 246

Acronym or Term
A.C.T.
ADP
ADW
AIU
ALJ
AMKC
Associate
Commissioner of
Operations
Assistant Commissioner
of Operations

Avoidable Incidents

AWOL
BHPW
BKDC
BWC
CASC
CD
CHS
CityTime
CMS
CO
COD
CLU
CLO
CMU
DA
DCAS
DOC or Department
DOI
DWIC
EAM

Definition
Advanced Correctional Techniques
Average Daily Population
Assistant Deputy Warden
Application Investigation Unit
Administrative Law Judge
Anna M. Kross Center
Positions reporting to the Deputy Commissioner of Operations that
oversee groupings of facilities.
New position to serve as Warden of each facility, the selection of
which is not limited to uniform staff. This role will report to an
Associate Commissioner of Operations.
Incidents that could have been avoided altogether if Staff had
vigorously adhered to operational protocols, and/or committed to
strategies to avoid force rather than too quickly defaulting to handson force (e.g., ensuring doors are secured so incarcerated
individuals do not pop out of their cells, or employing better
communication with incarcerated individuals when certain services
may not be provided in order to mitigate rising tensions).
Absent without Leave
Bellevue Hospital Prison Ward
Brooklyn Detention Center
Body-worn Camera
Compliance and Safety Center
Command Discipline
Correctional Health Services
Staff Member’s official time bank of compensatory/vacation days
etc.
Case Management System
Correction Officer
Central Operations Desk
Complex Litigation Unit
Command Level Order
Custody Management Division
District Attorney
Department of Citywide Administrative Services
New York City Department of Correction
Department of Investigation
Deputy Warden in Command
Enterprise Asset Management
xv

Case 1:11-cv-05845-LTS-JCF Document 517 Filed 04/03/23 Page 242 of 246

Acronym or Term

Emergency Response
Teams

EMTC
E.I.S.S.
ESH
ESU
Full ID Investigations
GMDC
GRVC
H+H
HOJC
HUB
ID
In-Service training
Intake Squad
IRS
JARs
LOS
LMS
MDC
MMR
MO Unit
MOC
NCU
New Directive or New
Use of Force Directive
Non-Compliance
NPA
OATH
OBCC
OC Spray

Definition
There are at least three types of Emergency Response Teams: (1)
Probe Teams, which consist of facility-based Staff (“Facility
Emergency Response Teams”); (2) the Emergency Services Unit
(“ESU”) which is a separate and dedicated unit outside of the
facility; and (3) the Special Search Team (“SST”), a separate and
dedicated unit associated with the Special Operations Division that
conducts searches.
Eric M. Taylor Center
Early Intervention, Support, and Supervision Unit
Enhanced Security Housing
Emergency Service Unit
Investigations conducted by the Investigations Division
George Motchan Detention Center
George R. Vierno Center
New York City Health and Hospitals
Horizon Juvenile Center
Housing Unit Balancer
Investigation Division
Training provided to current DOC Staff
A new dedicated unit within ID to conduct intake investigations of
all use of force incidents
Incident Reporting System
Joint Assessment and Reviews
Length of Stay
Learning Management System—advanced training tracking
platform
Manhattan Detention Center
Medically Modified/Restricted Duty Status in which Staff may not
have direct contact with incarcerated individuals.
Mental Observation Unit
Memorandum of Complaint
Nunez Compliance Unit
Revised Use of Force Policy, effective September 27, 2017
“Non-Compliance” is defined in the Consent Judgment to mean
that the Department has not met most or all of the components of
the relevant provision of the Consent Judgment.
Negotiated Plea Agreement
Office of Administrative Trials and Hearings
Otis Bantum Correctional Facility
Chemical Agent
xvi

Case 1:11-cv-05845-LTS-JCF Document 517 Filed 04/03/23 Page 243 of 246

Acronym or Term
OMAP
OSIU
Parties to the Nunez
Litigation
Partial Compliance
PC
PDR
PMO
PREA
Intake Investigations
Intake Squad
Pre-Service or Recruit
training
Rapid Review /
Avoidables Process
RMSC
RNDC
SCM
SDNY
Service Desk
S.R.G.
S.T.A.R.T.
Staff or Staff Member
Substantial Compliance
TEAMS
TDY
TRU
Trials Division

Definition
Office of Management Analysis and Planning
Operations Security Intelligence Unit
Plaintiffs’ Counsel, SDNY representatives, and counsel for the City
“Partial Compliance” is defined in the Consent Judgment to mean
that the Department has achieved compliance on some components
of the relevant provision of the Consent Judgment, but significant
work remains
Protective Custody
Personnel Determination Review—disciplinary process for
probationary Staff Members
Project Management Office
Prison Rape Elimination Act
All use of force incidents receive an initial investigation, or “Intake
Investigation,” which is a more streamlined version of the
predecessor “Preliminary Review.”
ID investigators conducting Intake Investigations
Mandatory Training provided by the Training Academy to new
recruits
For every actual UOF incident captured on video, the facility
Warden must identify: (1) whether the incident was avoidable, and
if so, why; (2) whether the force used was necessary; (3) whether
Staff committed any procedural errors; and (4) for each Staff
Member involved in the incident, whether any corrective action is
necessary, and if so, for what reason and of what type
Rose M. Singer Center
Robert N. Davoren Complex
Safe Crisis Management
Southern District of New York
Computerized re-training request system
Security Risk Group (gang affiliation)
Special Tactics and Responsible Techniques Training
Uniformed individuals employed by DOC
“Substantial Compliance” is defined in the Consent Judgment to
mean that the Department has achieved a level of compliance that
does not deviate significantly from the terms of the relevant
provision
Total Efficiency Accountability Management System
Temporary Duty
Transitional Restorative Unit
Department’s Trials & Litigation Division
xvii

Case 1:11-cv-05845-LTS-JCF Document 517 Filed 04/03/23 Page 244 of 246

Acronym or Term
TTS
UOF
VCBC
WF
Young Incarcerated
Individuals

Definition
Training Tracking Software system
Use of Force
Vernon C. Bain Center
West Facility
Incarcerated individuals under the age of 19

xviii

Case 1:11-cv-05845-LTS-JCF Document 517 Filed 04/03/23 Page 245 of 246

APPENDIX C:
FLOWCHART OF PROMOTIONS
PROCESS

xix

Case 1:11-cv-05845-LTS-JCF Document 517 Filed 04/03/23 Page 246 of 246

Flowchart of Promotions Process

DCAS Exam

Civil Service Requirements:
> U.S. citizen; 21 years old+; valid Driver's
License etc; language requirement; proof of
identity
> educational or experience requirements
>drug test; medical, psychological & physical
testing
> resident of NY or counties

DOC In-House Disqualifiers:
> dismissal from prior employment
> arrests total
> driving record total
AIU Background Investigation

Review of Candidate's
History/Background
Investigation by Director of
AIU and Assistant
Commissioner of AIU

Correction Officer

DCAS Exam
(Completion of probation - 3
Years CO, unless extended)

Disqualifiers
> must hold valid drivers license
> resident of NYor counties
> 60 college credits

Review of UoF, Disciplinary,
and other background
information

Commissioner to Review

Captain

DCAS Exam
(Completion of probation 1Year as Captain, unless
extended)

Disqualifiers
> must hold valid drivers license
> resident of NYor counties
> 60 college credits

Review of UoF, Disciplinary,
and other background
information

Commissioner to Review

Assistant Deputy Warden

Tele-Type Announcement
(Completion of probation - 1
Year as ADW, unless
extended)

Review of UoF and
Disciplinary History, and
Performance Evaluations

Re-Assignment Board Review
Rating, Interview, Candidates
Ranked

Commissioner to review
candidates recommended by
Re-Assignment Board

Deputy Warden

Tele-Type Announcement
(Completion of probation - 18
months in eligible title
(Captain/ADW/DW), unless
extended)

HR reviews UoF and
Disciplinary History,
and Performance
Evaluations

Commissioner to
review candidates
recommended by
Promotion Board

Promotion Board
Review, interview
candidates and make
recommendations

xx

Mayoral Approval

Warden