Blackburn Corectional Complex (002).pdf

COMMISSION ON ACCREDITATION FOR CORRECTIONS

STANDARDS COMPLIANCE REACCREDITATION AUDIT

Kentucky DOC

Blackburn Correctional Complex

Lexington, KY

September 18 - 20,2023

VISITING COMMITTEE MEMBERS

Michael Graziano, Chairperson

ACA Auditor

Carol Thomas

Michael Marutiak

A. Introduction

The audit of the Kentucky Department of Corrections, Blackburn Correctional Complex, Lexington, Kentucky was conducted on September 18 – September 20, 2023, by the following team: Michael Graziano - Chairperson, Carol Thomas - Member, and Michael

Marutiak - Member.

This audit review was conducted utilizing the Standards for Adult Correctional Institutions, 5th Edition. This was also a back-to-back audit with the Kentucky Department of

Corrections (KDOC), Division of Corrections Training.

B. Facility Demographics

Rated Capacity: 325

Actual Population: 274 (as of 7:00 am on the second day of the audit)

Average Daily Population for the last 12 months: 231

Average Length of Stay: 2 Years – 5 Months

Security/Custody Level: Minimum

Age Range of Offenders: 20-76

Gender: Male

Full-Time Staff: (128)

(38) Support, (6) Program, (83) Security, (19) Medical - Contract, (1) Mental health

At the time of this audit the facility had a total of (12) vacant positions. (6) of the vacant positions were security positions.

C. Facility Description

Blackburn Correctional Complex was made a part of the Kentucky Department of

Corrections in 1972 when it was transferred from the old Department of Child Welfare. It was named after former Kentucky Governor Luke P. Blackburn (1879-1883) who was noted for his prison reform. Prior to becoming part of the Kentucky Department of

Corrections, the institution was known as Kentucky Village. Kentucky Village housed approximately (600) juveniles from across the Commonwealth. Kentucky Village opened in 1897 and housed both boys and girls ranging from 8-21 years of age. (50) acres of the farm were used as a garden raised entirely by the boys. A brick-making machine was put into use in 1901 where boys made bricks to be used in the future buildings on campus.

Both boys and girls were taught how to do laundry, girls did mending, and made new garments as needed along with being provided cooking lessons. The girls also make jellies and preserves. The manual training shops produced chairs, brooms, harnesses, and a shoe shop for repairing shoes. In early 1902 there was a primitive carpenter shop with hopes of establishing a printing shop and the capability of making cabinets. The reform school utilized the Sloyd system of manual training in which woodworking skills were established.

The day began every morning at 5:30 AM alternating between classroom work and manual labor and ended at 8:00 PM nightly. 12:30 p.m. - 1:30 p.m. daily was reserved for playtime.

Today, Blackburn Correctional Complex (BCC) is the largest minimum-security institution in the state of Kentucky, which houses minimum and community custody male offenders.

The BCC operates a 325-bed adult male institution. All individuals incarcerated here have been convicted of felony charges. BCC has housing areas located in two buildings. Dorm

1 consists of four bays, A-D, totaling (96) general population beds. A-Bay has 32 beds, B-

Bay has 32 beds, C-Bay has 12 beds, and D-Bay has 20 beds. All beds are for general population inmates. This dorm operates under the unit concept and is staffed by a Unit

Administrator and a Classification and Treatment Officer. C-Bay houses the 4 Paws for

Ability program where inmates train therapy dogs. Dorm 2 consists of five bays, A-E, totaling (224) beds. A-Bay has 50 beds used to house new incoming inmates until the classification process is completed. B-Bay has (50) beds which (40) of these beds are dedicated for the Supporting Others in Active Recovery (SORE) program. C-Bay has (50) beds for general population, D-Bay has (50) beds used for the Substance Abuse Program

(SAP), and E-Bay has (24) beds used for general population. This dorm also operates under the unit concept and is staffed by a Unit Administrator and two Classification and

Treatment Officers.

The physical plant consists of (44) buildings that house Academic and Technical programs, and industrial and support services on over (400) acres of land. The institution also has a farming operation located on the grounds that is operated by the Agriculture and Dietary

Branch of the Kentucky Department of Corrections as well as a Thoroughbred Retirement

Foundation (TRF) program.

The farm has registered Angus cattle and vegetables. The cattle are sold on the open market by the Agriculture and Dietary Branch and the fresh vegetables are distributed to various institutions. Alfalfa and grass hay are also maintained. Vocational programs consist of horticulture and horse grooming. Prison Industries includes the Cattle Farm.

The mission statement for the Kentucky Department of Corrections states: To protect the citizens of the Commonwealth and to provide a safe, secure, and humane environment for staff and offenders in carrying out the mandates of the legislative and judicial processes;

and, to provide opportunities for offenders to acquire skills which facilitate non-criminal behavior.

The mission statement for Blackburn Correctional Complex states: We aim to provide the highest level of service with qualified and dedicated employees in order to accommodate offender needs, while focusing on conducting business in the safest manner possible. We strive to instill values of integrity, fairness, courtesy, and respect among staff and offenders in order to guide and alter offender behavior for a smooth and successful transition back into our communities.

D. Pre-Audit Meeting

Since this was a back-to-back audit with the KDOC Department of Corrections Training, the team met on September 17, 2023 in Lexington, Kentucky to discuss the information provided by the Association staff and the officials from both the Blackburn Correctional

Complex and the Department of Corrections Training.

The chairperson divided standards into the following groups:

Expected Practices #5-ACI-1A-01 - #5-ACI-3A-45: Michael Graziano, Chairperson

Expected Practices #5-ACI-3B-01 - #5-ACI-5F-08: Carol Thomas, Member

Expected Practices #5-ACI-6A-01 - #5-ACI-7F-08: Michael Marutiak, Member

E. The Audit Process

1. Transportation

The team was escorted to the facility each day by Shawn Earles, Mechanical

Maintenance & Operations Supervisor, and Jason Joseph, Administrative Branch

Manager of Accreditation and Policy.

2. Entrance Interview

The team met with Warden Abby Caudill and her Executive staff at 8:00 a.m. on

Monday September 18, 2023.

Present at that meeting was:

Abby Caudill Warden

Michelle Smith Captain

Jason Joseph Administrative Branch Manager of Accreditation and Policy

Lee May Procedure Development Specialist II

The team expressed the appreciation of the Association for the opportunity to be involved with the BCC in the accreditation process.

It should be noted that on August 7, 2023, Deputy Warden Belinda Sanchez was killed in an automobile accident. Belinda was an integral part of Blackburn

Correctional Complex and her passing affected and sadden everyone at the facility.

On behalf of ACA, the team expressed their sincere condolences.

The audit team advised Warden Caudill that our goal was to be helpful and non-intrusive to his operations. We discussed the use of the 5th Edition manual and asked for distance from staff when interviewing inmates. We did ask if there was any interest from staff or inmates to speak with the audit team. There was none.

We did promise the Warden a fair and thorough review.

The audit team then proceeded to the facility chapel to meet with key staff. The following staff were present for this initial meeting:

Kathryn Aquadro Librarian

Tiffany Arnold Social Service Clinician

Andrea Becker Psychologist

Thomas Bull Recreation Manager

Marika Burns Unit Administrator I

Charles Carter Human Resources

Abigail Caudill Warden

Reginald Davis Chaplain

Shawn Earles Mechanical Maintenance & Operations Supervisor

Jonathan Faulkner Information Technology

Daniel George Internal Affairs

Monica Godbey Inmate Accounts

Andrew Hartley Classification & Treatment Officer

Joel Helmburg TRF Farm Manager

Lyndel Hester Captain

Angela Holbrook Fiscal Manager

Cathi Johnson Unit Administrator I

Sharon Johnson Warden’s Secretary

Jason Joseph Administrative Branch Manager of Accreditation and Policy

Charles Kahn Academic Supervisor

Royia Manley Program Administrator

Lee May Procedures Supervisor

Allison Medley Unit Administrator II

Brenda Messer Health Services Administrator

Haley Nesselrode Mechanical Maintenance and Operations Supervisor

Enrique Relford Maintenance Assistant

Christina Seibold Procedures Assistant

Edward Smith Payroll

Michelle Smith-Maynard Administrative Captain

Sarah Stoops Tool Room

Courtney Tudor Classification & Treatment Officer

Jessica Vanburen Social Service Clinician

Gayle Walker Maintenance Branch Manager

Wendy Walrod Records Supervisor

Sean Wells Purchasing Officer II

3. Facility Tour

The team toured the facility from 8:30 a.m. to 2:00 p.m. with a break for lunch from

12:00 p.m. – 12:40 p.m. The following persons accompanied the team on the tour and responded to the team's questions concerning facility operations:

Abby Caudill Warden

Christina Seibold Procedures Assistant

Michelle Smith Administrative Captain

Sharon Johnson Warden’s Secretary (scribe)

Shawn Earles Procedures Assistant (scribe)

Lee May Procedure Development Specialist II

Haley Nesslerode Mechanical Maintenance & Operations Supervisor

Jason Joseph Administrative Branch Manager

Facility ACA notices were observed posted throughout the facility.

4. Conditions of Confinement/Quality of Life

During the tour, the team evaluated the conditions of confinement at the facility.

The following narrative description of the relevant programmatic services and functional areas summarizes the findings regarding the quality of life.

Security:

BCC does not have a secured perimeter and is an open campus design. The facility has two Checkpoints (Posts) that monitor traffic in/out of the facility. Checkpoint

#1 monitors all traffic entering the front of the facility. Each vehicle is stopped, identification checked, a visitor tag given to a visitor, and the vehicle is checked.

Checkpoint #2 is in the rear area of the facility and monitors all delivery vehicles to the facility. All delivery vehicles are escorted by security staff to either the warehouse or the kitchen. BCC utilizes (227) cameras to monitor the facility and perimeter for inmate movement and the security of the institution. The facility has a digital video recording system and currently retains recording for (30) days. The cameras are monitored in the Control Center and accessible in the offices of Internal

Affairs, Captain, Warden, and Deputy Warden.

When entering the Administration Building, all individuals must remove all items from their pockets, coats/jackets, belts, shoes, etc. These items are then run through an x-ray machine and inspected by staff. All individuals are then expected to clear a walk-through metal detector.

BCC operates on three work shifts: 1st shift is 8:00 a.m. to 4:00 p.m., 2nd shift is

4:00 p.m. to 12:00 a.m., and 3rd shift is 12:00 a.m. to 8:00 a.m. The oncoming shift reports for a pre-shift briefing. The briefing is conducted by the shift commander and provides officers with relevant recent facility activity information as well as training opportunities, announcements, and a brief review of policies and procedures. Officers receive additional information from the off-going post officer upon arriving at the assigned post.

The facility has one Central Control Center. The central control is in the main hallway of the administration building and staffed with correctional officers on all shifts. The security staff are responsible for monitoring cameras, communications, fire control panels, internal radio traffic and take incoming calls to the institution.

The fire alarm annunciator panel and the radio base station are located in the control center.

The facility conducts five formal counts Monday thru Friday: 7:15 a.m., 12:15 p.m., 3:15 p.m., 6:00 p.m., and 8:45 p.m. There is an additional 10:00 a.m. count on weekends and holidays. Formal counts require the inmates to be standing at their bed area and displaying their ID card. There are four informal counts throughout the day. The informal counts are conducted at 11:00 p.m., 12:15 a.m., 3:00 a.m., and 4:30 a.m. Informal count is a visual count conducted by the dorm officer checking for flesh and movement. The 7:15 a.m. formal count on day three of the audit was witnessed by the audit team in both housing unit. Two officers take the count in each unit. One officer walks and checks the inmate ID while counting and the other officer stays in the dorm and also counts the inmates. Both officers then compare their numbers to ensure their counts match. The total number is then phoned into the control center. The control center will respond if the count supplied to them was a good count.

BCC’s armory is located inside a small building located outside of the Post 1 entry gate. The armory cannot be accessed while there is anyone in the facility entry gate area. BCC has two assigned armorers: one Lieutenant and one Captain. The armorers are not certified by the weapons manufacturer, however, have received the Kentucky Department of Corrections Firearm Certification. The armory consists of one room containing lockers for transportation weapons and gear as well as a gun locker for local law enforcement if needed. The armory has limited access and is secured by a solid locked door. The armory was very clean, neat, and organized, displaying that the armorers take considerable pride in their area of responsibility.

The Arsenal is equipped with the following weapons: (24) Glock 23 (12)

Remington 870 shotgun, eight Tasers, two AR 15, one gas grenade, and two Pepper ball guns. Associated ammunition, variety of chemical munitions, OC, and several types of restraints (handcuffs, leg irons, waist chains, etc.) are also stored here.

Weapons, ammunition, and chemical munitions are clearly marked and stored separately. Expired chemical munitions are used for training. Inventories and inspections are maintained and conducted in accordance with policy for all weapons, ammunitions, and chemicals. Spot check of inventories was conducted with no deficiencies found.

Key control is supervised and managed by a Lieutenant and the key control sergeant. Both are certified locksmiths and have responsibility for the inventory and replacement management of locks and keys. Replacement keys are cut on-sight as needed.

The facility uses the “Key Tracer” electronic key box system for the storage and issuance of operational keys. Currently, the Key Tracer holds (224) sets of institutional keys. There are three key boxes located in the administration building hallway adjacent to central control. Staff use a biometric finger scan at the issuance station to receive and turn-in keys. Once the scan is completed the individual select/inputs the key set number needed. The key box alerts the key location so keys can be retrieved. The return of the keys in done in the same manner. The key control sergeant sets key permissions so that only assigned keys can be accessed by an individual.

All operational and emergency keys are appropriately identified, numbered and on tamper proof rings. Color coded key fobs are used to identify and categorize keys;

green are operational general use keys, yellow are restricted keys, blue is the K9 officer’s keys, black are vehicle keys, and red are emergency keys.

All operational and security key blanks are secure, stored in the armory and inventoried as required by policy. A spot check of operational and security keys was conducted with no deficiencies found. Broken or damaged keys are managed according to policy. Key destruction is approved by the Chief of Security and handled by the maintenance department.

BCC tool control sergeant manages the facility’s tool control. The main tool room is located inside the Maintenance Department. The facility has two classifications of tools: Class A and Class B. Per policy Class A tools and equipment pose a serious risk to the facility. The use of such tools and equipment will be restricted to a specific area under direct staff supervision. All tools were stored in cages, identified, and displayed on shadow boards. Class A and Class B tools and equipment are secured in lock cages and issued using a “Tool Control Log” issuance log.

Tools carts were found to be shadowed and inventories were present. Additionally, tools are located in various areas throughout the facility, food service, warehouse, medical and vocational areas. Tools are inventoried daily by department/area supervisors and quarterly by the tool control officers. Inventories were checked by a visiting committee member with no deficiencies found. Proper procedures are in place to manage the destruction of broken tools.

Post orders were reviewed in various locations throughout the audit. The documentation that was reviewed shows that staff are reading post orders prior to assuming their post.

Beginning in November of 2020, BCC began a Temporary Assessment Center

Program to help with overcrowding in the jails. In the past, Roederer Correctional

Complex (RCC) was initially the only adult male Assessment Center. Now BCC and four other correctional units assist with inmate intakes. Upon intake, inmates are not given haircuts but do receive a delousing shower. All required information such as an inmate orientation manual and PREA information is distributed at this time. BCC is currently housing new admissions from jails in Dorm 2. Due to this change, the following ten (10) ACA standards are now applicable for BCC: 5A-01, 5A-02, 5A-03, 6A-19, 6A-21, 6A-23, 6A-24, 6A-25, 6A-31, and 6A-32.

The Crisis Negotiation Team (CNT) currently has ten members. The team can be activated for various reasons from verbal altercations to more extreme behaviors.

The CNT deploys active listening skills to get to the root of the problem. Members receive an initial (40) hours of training and eight hours a month after that.

The facility has a Tracking Canine Team. The program consists of five canine officers of varying rank from lieutenant to officer and three tracking bloodhounds named Mikey, Rambo, and Wheller.

Special Management and Restrictive Housing

All Expected Practices related to Special Management (#5-ACI-4A-01 through #5-

ACI-4A-27) were found to be Non-Applicable to BCC. In addition, all expected practices related to Restricted Housing (#5-ACI-4B-01 through #5-ACI-4B-34) were also found to be Non-Applicable to BCC. The facility does have five holding cells used for inmates that needed to be transferred from BCC. These individuals are transferred within (72) hours.

Environmental Conditions:

The environmental conditions at the BCC were good. The facility in general has a good inmate climate, with good inmate/staff relations. The temperatures of the facilities were within normal comfort range. Noise levels throughout the facility were within acceptable ranges. BCC is a tobacco free environment.

All interior light fixtures observed were in good working order. Both housing units had adequate ventilation and there were no noticeable odors. Lighting levels were well within standards. The general condition of the entire complex was clean. Both housing units have an appropriate number of sinks and toilets that are easily accessible to all inmates. The inmate living areas were clean and personal items neatly stored.

Sanitation:

The facility has a well-established Housekeeping Plan. Sanitation and cleanliness was good. Sanitation of the facility is under the supervision of the

Maintenance Supervisor with (24) inmate workers. Inmates are given daily cleaning assignments throughout the complex. Inmates are also trained in biohazard cleanup. These trained inmates are on call and a list of qualified inmates is kept in the security control center. The visiting committee visited all areas of the facility, including bathrooms, showers, toilet areas, housing units, staff restrooms and break areas, inmate program areas, visiting areas, medical and healthcare areas. It was clear that housekeeping plans, manuals, and schedules were being followed. Cleaning supply inventories were checked and found to be accurate.

The facility contracts regular pest and/or vermin control via a professional exterminator. Certified and approved vendors provide pest control and waste management. All services for drinking water and sewage are provided by the city of Lexington. Furnishing throughout the facility was in good condition and fire rated as required by policy.

Fire Safety:

BCC has a Safety Officer assigned to manage and direct the fire prevention and safety program.

The facility’s fire suppression system includes sprinkler system with eleven risers,

(642) smoke detectors, (130) duct detectors, (25) heat detectors, (18) manual pull stations with annunciator panels in Central Control Room, Administration area, and the primary is in the closet off the maintenance hallway. The kitchen has an Ansul wet chemical suppression system for the hoods.

All fire systems are inspected, tested, and serviced in accordance with the manufacturer’s recommendation and all systems were operational during the audit.

Equipment is serviced as required and routine inspections are conducted by qualified staff. There are an ample number of fire extinguishers located throughout the facility and are inspected in accordance with policy. There are (163) ABC fire extinguishers, one AB extinguisher, and eleven Halon hydrants.

Inspections, testing, and services were conducted:

• Deputy Fire Marshall’s inspection June 2023

• Sprinkler system - Johnson Controls - May 2023

• Fire Panel inspection - Johnson Controls- May 2023

• Hood suppression system – Hoodz – February 2023

• Health Inspection – August 2023

• Fire extinguishers - inspected monthly by the facility’s fire/safety department

The complex is supported by the full-time Lexington Fire Department Station 24 located 1.3 miles from the facility with a five-minute response time. Bolivar Fire department is located (15) miles away with a response time of 5-to-20-minutes.

The facility’s fire plan is reviewed and approved annually by the State Fire Marshall and in compliance with all applicable state fire safety regulations. Primary and secondary exit evacuation routes are clearly marked in all housing units and throughout the facility. Exit signs and emergency lighting were present and functioning during the audit.

The facility staff uses proper storage procedures and inventory control for caustics and toxic materials. Chemical products are stored in labeled containers and Safety

Data Sheet (SDS) information is readily available. The SDS are kept in all proper locations for the use and immediate review of the appropriate first aid required in the event of an emergency. They were well organized.

Food Service:

BCC food service is operated through a private food service contract with

ARAMARK. The food service department is staffed with one Food Service

Director, four hourly employees, and (36-40) inmate food service workers. At the time of this audit the position of Director and one hourly employee was vacant.

The kitchen includes walk-in refrigerators and freezers, a dry storage room, food prep areas, cook prep areas, one inmate dining hall, chemical storage room, tool room, staff offices and staff and inmate restrooms.

The facility follows a four-week rotating heart healthy diet menu. The menu is designed to deliver approximately (2600) calories daily and is approved by a certified ARAMARK Dietitian. The ARAMARK dietician completes a nutritional analysis on the menus to ensure it meets the minimum daily requirements recommended by the American Dietary Association (ADA). Dietary reviews of meals served were documented and provided for review.

The average daily meal cost is $1.33. Meal serving times are: Breakfast – 5:15 a.m., Lunch - 10:30 p.m., and Dinner - 4:30 p.m. Mealtimes can be adjusted slightly based on the facility count clearing.

The visiting committee consumed the lunch meal on Tuesday, September 19, 2023, consisting of:

• Taco filling (1// cup)

• Spanish Rice (1 cup)

• Salsa (1green /2 cup)

• Chocolate brownie (1 piece) Margarine (1 #2 scoop)

• Tortilla chips

• Beverage drinks

The meal was tasty, palatable, and presented well on the tray. Portion sizes were in accordance with the approved menu.

The facility provides therapeutic and religious diets. At the time of this audit there were (30) inmates on therapeutic diets with a (2,200) calorie intake. However, the facility does not offer a kosher diet.

Any inmate requiring a kosher diet would be transferred to a different facility. The diet handbook was on-hand and available for review. The facility does offer an alternate no meat entrée at each meal.

BCC has one inmate dining hall with the seating capacity for (125) individuals.

Each dining hall is equipped with stainless tables with four permanently affixed stools. All dining rooms have tables that are wheelchair accessible.

Food service tools are etched and properly displayed on shadow boards stored in a locked cage with an issuance log in place for accountability. Verification and review of tools signed out/in procedures was conducted and tools were all accounted for accurately.

Temperature checks and logs for walk-in refrigerators, freezer, dry storage area and dishwasher were reviewed and showed no discrepancies in maintaining appropriate temperatures. Manual dishwashing sink temperatures were found in compliance as well as the chemical sanitizer concentration met the manufacturer recommended strength.

Food Service chemicals are secure; inventories were checked, and the system is well managed. (SDS) are present where all chemicals are stored and personal protective equipment is available for use.

Medical Care:

Note: The audit period under review overlaps with the state of the worldwide

COVID-19 pandemic and related restrictions. All the practices and programs listed below were affected to some degree, substantially or minimally.

The Blackburn Correctional Complex (BCC) experienced a peak in COVID-positive cases in January of 2021 when over 300 inmates were positive. At the audit time, there were no known positive cases and no inmates in medical quarantine for

COVID-related reasons. Vaccinations (Moderna) are available to inmates.

Documentation shows that 61% of the inmate population is vaccinated.

Observed protocols still in place include hand sanitizers and physical distancing at times, vaccines offered to all inmates, COVID screening questions at intake, and increased cleaning. Face masks are optional for staff and inmates. The BCC

Health Care staff was quite initiative-taking in adhering to the current COVID-19 management practices, as was the ACA Audit Team.

Resources and Locations:

The BCC medical services are provided under contract with Wellpath. Dental and mental health services are provided by others under contract with the KDOC.

Certain services such as radiology, ultrasound, and optometry are provided onsite through outside contracts. Telehealth is used.

The BCC medical services are in a multipurpose building, squarish-type area, near the front of the complex. The area itself appeared well lit with adequate workspace for the staff and services. A member of the audit team visited and inspected the location several times. Dental services are located adjacent to the medical area.

Mental health is in a separate building where inmate-intake processing takes place.

The design of the medical hallways and doors can accommodate handicapped inmates if needed. The examination rooms allow for a measure of privacy from non-medical personnel during examinations or procedures by means of limited inmate movement in the area, the placement of examination tables and, if warranted, a privacy screen and/or curtains. The examination rooms and offices have solid doors with small windows. An officer can be stationed inside or outside of the examination rooms, depending on the situation.

The medical area itself has two entrances and a waiting area for about 15 inmates, with various health care posters and access to a restroom on request, one treatment room, a laboratory room, an IV room, offices for a provider, HSA, Medical

Director, and Unit Supervisor, an office for the administrative assistant, the dental office and area, a medication room, an optometry office, a staff breakroom, and various storage closets for office supplies, oxygen supplies, medical supplies, and general storage. There is also a medical room in the intake area. The BCC does not have an infirmary or a medical housing unit or a negative pressure room. Inmates with health-related concerns and those with ADA classifications are housed in

Dorm 2 but not exclusively.

The adjoining dental area has two operatory chairs and an office. The mental health area has one staff office with a sizeable adjoining room.

A designated van is parked near the outside door of Health Services for rapid transport around the large facility and grounds.

A standard of cleanliness, hygiene and orderliness was observed. Staff in all areas had an accommodating and constructive attitude about the ACA audit. All noted areas appeared well organized when viewed by the audit team.

Staffing for Health Care:

Medical:

Physician and Medical Director - part-time – one day a week

(Position recently vacated when the physician died weeks before the audit;

Regional Medical Director on call)

Nurse Practitioner – part-time – 2.5 days a week at the BCC

Nurse Practitioner (vacant position)

Psychiatric Mental Health Nurse Practitioner – part-time – one day a week

Health Services Administrator (HSA)

Registered Nurse Charge Nurse (vacant position)

Registered Nurses (3)

Licensed Practical Nurses (4)

Licensed Practical Nurse, part-time

Administrative Assistant

Optometrist – part-time – contracted through KDOC – one or two days a month.

[Notes: There are three other nurses, RNs and LPNs, on a PRN basis. The health care staffing plan is established by contract with the KDOC.]

Dental:

Dentist – part-time – one day a week – contracted by the KDOC with Mid-America

Health, Inc.

Dental Assistant - part-time – one day a week – contracted by the KDOC with Mid-

American Health, Inc.

Mental Health:

Licensed Psychological Associate – employee of the KDOC

Medical Records:

The medical records are kept in electronic format through the EDMIS system, with a list of authorized people/positions to access the records. Medications are managed and recorded electronically. The records are accessible by other authorized KDOC or medical staff if an inmate is transferred.

An auditor viewed copies of records for the chronology of entries, consistency of entries, and orderliness of documents. The auditor noted the provider orders, progress notes by clinicians and the initial mental health screenings. The medical records are organized into (11) distinct sections with tabs separating the respective sections and documentation or notations in reverse chronological order. Older paper records were scanned into the electronic system and then sent to retention at the Roederer Correctional Complex for a 20-year retention period.

Infirmary, Medical Housing, and Medical Observation:

The BCC does not have an infirmary or a specialized medical housing unit. If the situation of infirmary care arises, an inmate would be sent to a KDOC-infirmary facility such as the Kentucky Medical Center or the Kentucky State Reformatory, or to a hospital. (5-ACI-6A-09)

The BCC does have five holding cells in the intake area for short-term observation or confinement. The cells are equipped with toilets and basins (ratio 1:1). The cells have video monitoring.

Services and Care:

The BCC has 24/7 onsite medical care. Clinic hours for the provider are consistent with business hours. Nurses are on 12-hour shifts. Nighttime and weekend emergencies are managed by nursing staff who can contact a provider by telephone or virtually if more than the authorized nursing protocols are needed.

The BCC receives both intra-system and inter-system intakes though the larger proportion is the intra-system group. Conditions that result in transfers to a more appropriate facility include serious mental illness (SMI) and severe chronic cases.

Provided services at the BCC include orientation, in-take screening, emergency care, sick call, pill call, dental, areas for physical therapy, treatment management plans, stable chronic care (including infectious diseases, cardiovascular, hypertension, diabetes, cancer, seizures, Hepatitis A, B and C, HIV infection, insulin dependent diabetics, renal, and gastrointestinal), periodic reviews for chronic care, health exams, mental health, laboratory, and referral for specialty care. Individual risk factors are reviewed in relation to hepatitis conditions.

Services by outside providers are provided both onsite and offsite.

Upon admission to the BCC all inter-system transfer reception and intra-system inmates (from KDOC facilities) are initially screened by a nurse (normally an RN) for medical, mental health and dental issues. The initial screening and later orientation include information on Self-Administered-Medication (SAM) medications (aka, “KOP” medications), “sick-call” procedures, access to medical and mental health services, a handbook, and other educational guides. A checklist form is used to ensure all points are covered with the inmate and the inmate signs for his acknowledgement of the same.

The BCC uses electronic forms for the inter-system intake screenings (“Condensed

Health Services Encounter,” DOC #264083) (M-5-ACI-6A-22). A similar electronic form is used for intra-system transfers (“Intake Screening”, DOC

#264803). Both types of intake screenings are accompanied by a mental health appraisal by the mental health professional. Within (14) days of an inter-system intake, inmates are seen by a practitioner for a more comprehensive evaluation and history – the health care physical assessment (5-ACI-6A-25).

Health education for inmates includes the initial orientation and screening, signage and pamphlets, chronic care clinic assessments, a handbook with a comprehensive explanation of services and processes with separate sections on how to access medical care, dental care, and mental health, personal hygiene, some substance use disorder information from nursing staff, and handouts in the medical areas for inmates.

As already noted, the inmates sign a form at orientation to acknowledge their understanding of how to access health care. Information is available in English and

Spanish and, if needed, translation services are available through Language Line.

(M-5-ACI-6A-01)

An individual treatment plan (ITP) is written for all inmates in the chronic care category. Known or reported chronic care issues are documented on the initial screening sheets. Chronic care plans are reviewed with the inmates as ordered by the provider but at least on a schedule of every six months and during periodic examinations (M-5-ACI-6A-18). The facility follows a Management of Chronic

Disease Plan. An auditor viewed several records of chronic care inmates and individual treatment plans for medical, dental, and mental health. Those inmates experiencing difficulties with the control of their chronic care condition(s) are seen on a more frequent basis. Chronic care treatment plans include a review of medications, diagnostic tests, subjective and objective findings, and a review and update with the inmates. At the time of the audit there were (329) inmates in the various chronic care clinics (counting an inmate multiple times if he was enrolled in several clinics). The larger enrollments are in clinics for Hepatitis C, hyperlipidemia, and hypertension.

Sick-call requests, medication refills, and clinical and specialty services are routinely initiated through a simplified (and effective) system: inmates complete a

“sick call request” form – for medical, dental, or mental health – then put the form in a locked box for daily collection and triage by medical staff. If an inmate is unable to complete his own sick call request due to impairment or disability, a nurse will assist him during the time of pill call. Inmates with symptoms of concern are normally seen on the same or following day. Sick call referrals for an inmate may be generated by any staff member. To give a perspective, health care at the BCC receives (80 to 180) sick-call requests a month, including those for dental or mental health services.

The most recent monthly “Site Progress Report” filed by the HSA shows only a small number of pending clinical services and no backlogs in many categories such as health assessments, the eye clinic, etc.

Periodic health examinations are scheduled every year for inmates (50) years of age and older and every three years for those under (50). All chronic care inmates receive examinations every year.

Tuberculosis testing of inmates is done upon intake (as is voluntary HIV testing) and annually thereafter. Testing is also done for any inmate displaying symptoms of tuberculosis or for any inmate in contact with a known or suspected TB case.

Regarding the TB testing of all direct care employees (custody staff, civilian staff with inmate contact, etc.), the facility provided documentation of the testing upon hire and prior to job assignment and periodically thereafter (5-ACI-6B-05).

A very readable list of 24-hour emergency medical, mental health, and dental contacts is maintained, as is a protocol on the step-by-step process for offsite emergency care. The list also contains current off-hours contact information for health care staff. Minor-type emergencies are managed on site. The outside hospital frequently utilized is the University of Kentucky Medical Center about five miles away. For emergencies, the Lexington EMS is dispatched and a memorandum of understanding for that service is in the ACA files.

Written plans are in place for onsite emergencies, emergency vehicles, designated hospitals, and security for transport. Written plans are also in place for the management of Hepatitis A, B, and C. An Exposure Control Plan is in place, as is an Infection Control Manual.

Health Care services provide adaptive devices such as canes, crutches, hearing aids, eyeglasses, walkers, and dentures for inmates, as necessary. An auditor viewed some of the items and reviewed past provider orders for them. The items appeared organized and sanitized. An inmate can be transferred to a disability placement program at another facility.

Although no physical therapist is onsite, a therapist can be accessed via telehealth.

Areas for physical therapy include the exercise yards, the gym and weight rooms, and housing units. Wellpath provides any special equipment needed for physical therapy, such as resistance bands.

Any severe withdrawal management cases from alcohol, opiates, hypnotics, stimulants, and sedative hypnotic drugs would be treated symptomatically by medical staff according to protocols and/or sent to one of the outside hospitals or inpatient facilities (M-5-ACI-6A-41). Narcan is maintained only in the medication room and the emergency bag. An auditor suggested broader maintenance of Narcan in other areas of the facility such as the Mailroom, the Control Center, the

Academic area, the Administration area, etc.

Laboratory specimens are taken at the BCC (a “draw lab” only) so the specimens can be processed by Lab Corp., who collects the specimens Monday to Friday.

Providers and medical staff at the BCC then receive the results for review. STAT labs can be provided by the local hospital.

The copay charge for routine sick-call appointments is three dollars, excluding mental health services, staff-initiated requests, follow-up appointments, indigency, etc.

Medical staff were aware of a maximum 4-minute response time to urgent calls.

Documentation of “drills” in the files demonstrated the participation and involvement of medical staff (M-5-ACI-6B-07). There was documentation of medical staffs’ training in the facility’s emergency responses. An inmate grievance process, both informal and informal, is in place.

The HSA responds at the first step of an inmate grievance. Appeals are decided by a joint Grievance Committee comprised of both Wellpath and KDOC members.

Six AEDs are in place in the facility: in the medical area, in both housing units, in the control area, and in the gym. The audit team did recommend moving the AED in the gym area to make it more accessible to staff. The Health Care area maintains an emergency “jump bag,” including an inventory of its contents, along with an

AED and oxygen, all of which are checked daily by nursing staff. Security staff are trained in the use of an AED. Mindful of comments made in the 2021 ACA

VCR about the BCC’s security staffs’ unawareness of the location of AEDs, the present audit team questioned security staff to learn they are now aware of an

AED’s nearest location and prepared to administer the same when needed prior to medical staff’s arrival.

The facility has (22) first-aid kits placed around the facility in addition to those in vehicles. The kits are in the housing units, the control area, the program buildings, Food Service, and on the farm, among other places. An auditor did note that the kit in Food Service was incomplete according to the inventory list and it had a broken container. The kits are checked monthly by medical staff (except for the

Food Service kit which may be an Aramark item) or when brought to them by other staff after use.

Medically ordered diets for inmates are available. Said diets are approved by the medical provider. The medical department conveys the orders to the Food Service

Department in writing where a daily list is maintained. There are (30-40) inmates on therapeutic diets at any point in time.

The BCC does not employ inmate assistants for familiar duties to assist other inmates with activities of daily living, peer support, and hospice-type activities. No students, interns, residents, or volunteers were used in health care during the audit period. Policies are in place should inmate assistants, students, et al, be used (5-

ACI-6B-10, 5-ACI-6B-11, and 5-ACI-6B-12).

Inmate interviews gave the impression that inmates do not view Health Care as part of the BCC security operation, an impression that leads to better and more honest communications between the inmates and Health Care staff. Inmates overall, when asked, had no complaints about Health Care services. Inmates expressed general satisfaction with the timeliness of medical callouts and responses. The audit team was well satisfied with the documentation and interviews demonstrating a continuity of care from intake to discharge or release.

Medication Room:

All medications are ordered through Diamond Pharmacy in Pennsylvania by means of an electronic system and are normally delivered within (48) hours.

There is a back-up, local pharmacy for urgent matters. The administration of medications is recorded on the MAR system.

Most medications, excluding some controlled substances, are received in blister packs, and administered at the “pill window” on the medication room wall, three times daily. There are additional times for diabetic lines. SAM blister packs are allowed.

The medication administration process follows usual protocols: inmates present their ID cards, the nurse checks the ID and the Medication Administration Record

(MAR), and a mouth check is performed to ensure swallowing and discourage hoarding. A security officer is stationed outside of the pill window. A range of

(700 – 1050) prescriptions are filled each month. OTC medications are issued from medical and selected ones are also available in the commissary.

An inventory of medications is done at the beginning and end of each shift by two nurses. Refrigerated medications were maintained at a proper temperature. The limited number of controlled substances present are inventoried at the beginning and end of each shift by two nurses using a separate logbook. Controlled substances are maintained behind two locks. An audit team member randomly checked medication inventories and found them to be accurate. The stock medications are inventoried every week and re-ordered as needed. All inventory records viewed were dated and initialed or signed.

An audit team member viewed the current formulary (October 2020 version), the process for disposal of biohazard materials, and the current licensing and certification for health care staff and the medication room. No abnormalities or lack of documentation was noted. Decontamination protocols are used daily. A process is in place for obtaining non-formulary medications if needed.

The BCC is one of only three Kentucky prisons with a Supportive Assistance

Medication for Addiction Treatment (SAMAT) program, with the goals of preventing relapse and facilitating an inmate’s transition into an outpatient program. Inmates who are participating in or who have completed the Substance

Abuse Program (SAP) at the BCC are eligible. Vivitrol and Suboxone/Sublocade are used.

Expired or discontinued medications are sealed and later returned to Diamond

Pharmacy, when possible, except for controlled substances which are destroyed by the HSA and Charge Nurse and witnessed by two other nurses. An inspection of the medical room is conducted quarterly by a Diamond pharmacist. A yearly audit of the medication room is done by Wellpath. No serious medication errors were noted in the Outcome Measures. The audit team found compliance with all the elements of M-5-ACI-6A-43.

Protocols for Sharps, Instruments and Biohazard Waste in Medical Areas:

An audit team member reviewed the inventories for sharps, syringes and instruments maintained in the Health Care areas (medical and dental). Inventories were randomly checked. The audit team member found the inventories to be accurate and consistent. Documentation showed that the perpetual inventories for sharps, syringes and instruments were conducted daily at the beginning and end of each work shift (for dental, on days staff are present). Past daily inventory sheets were maintained and available for the auditor. Usage of sharps could be cross-checked by means of the sick call notations and/or a “use log.” All items were securely stored. Bulk inventories are checked monthly.

Medical staff count sharps at an early point: when a supply of boxes is received

(i.e., even though the sharps are not needed at the time, the boxes are opened to verify the count, repackaged into smaller groups), and then re-taped to show a count was done).

Medical staff (as well as dental) maintain a “photo book” for all sharps and instruments, so, in the event of an unaccounted item, a photograph can be distributed to security staff, among other reasons.

Biohazard waste is safely and separately stored and collected monthly or as needed by the Stericycle company. An audit team member observed biohazard waste stored and secured in proper containers. The larger containers are kept in a locked room used exclusively for biohazard waste.

An autoclave is maintained in the dental area for dental and medical instruments.

A log is kept of the usage, time, temperature, pressure, results, and operating staff member for the autoclave.

Quality Improvement Program:

There is a Quality Improvement program (“CQI Meeting”) as well as regularly reviewed health care specific goals and objectives in place at the BCC, all documented in the audit files. Custody and administrative staff (Warden, Deputy

Warden, Classification, Captain, Training Coordinator, Safety Coordinator, and

Human Resources, and others) are committee members in addition to the medical and mental health staff. Components of the program are the utilization of management reviews, a health records review, risk management, mortality reviews, and staff development. The CQI meets quarterly. (M-5-ACI-6D-02) The Medical

Administration Committee (MAC) also focuses on performance improvement.

The MAC and CQI meetings are combined. An annual Quality Improvement Plan with goals and objectives for the medical area is approved and evaluated by the

HSA. The medical area also submits a monthly “Health Care Services” report to

Wellpath with data on medical, dental, and mental health services, treatments, hospital transfers, intakes, testing, chronic care, medications, staffing, etc.

Minutes from a series of meetings were reviewed by an auditor. The minutes and accompanying charts showed a system for collecting, trending, and analyzing data and then moving to a reassessing stage and then to action steps and assignments.

Examples of topics at the CQI meetings included, risk management reports and statistics, infection control, inmate grievances, environmental inspections, and corrective action plans. Health Care outcomes are monitored on a regular basis, as shown in the meeting minutes.

A Treatment Team Meeting is conducted monthly with the psychologist, directors of the substance abuse programs, caseworkers, and Chaplain. No interviewed staff member in the health care areas expressed any concern or experience of having health care decisions overridden or interfered with by non-medical staff; to the contrary, most staff members described a comfortable and effective working relationship with the non-health care departments.

Documentation was present to show that an external peer review of the physician

(recently deceased) was done in 2021, and that reviews for the dentist were done in

2021 and 2022. External reviews for the psychologist (a KDOC employee) were done in 2021 and 2022. Only confirmation memoranda (not the actual reviews and criteria) were provided. An auditor concluded that the external review documentation was satisfactorily consistent with M-5-ACI-6D-03, though copies of the actual reviews should be available to auditors.

Dental Care:

The…