COMMISSION ON ACCREDITATION FOR CORRECTIONS

STANDARDS COMPLIANCE REACCREDITATION AUDIT

Little Sandy Correctional Complex

Sandy Hook, Kentucky June 25-27, 2025

VISITING COMMITTEE MEMBERS

Shelia Oubre, Chairperson

ACA Auditor

Michael Marutiak ACA Healthcare

Auditor

Jessica Mallone ACA Auditor

A. Introduction

The audit of the Little Sandy Correctional Complex, in Sandy Hook, Kentucky was conducted on June 25-27, 2025, by the following team: Shelia Oubre, Chairperson, Michael Marutiak, Member and Jessica Mallone, Member.

B. Facility Demographics

Rated Capacity: 1050

Actual Population: 1008

Average Daily Population for the last 12 months: 1015

Average Length of Stay: 1 year and 7 days

Security/Custody Level: Medium/Minimum

Age Range of Offenders: 19 to 85

Gender: Male

Full-Time Staff: 250

(26) Administrative, (11) Support, (34) Program, (179) Security, (0) Other

C. Facility Description

The Little Sandy Correctional Complex (LSCC) is located in the city of Sandy Hook, Kentucky, which is located in Elliott County Kentucky. It is the state’s newest and most technologically advanced institution. Construction on LSCC, began in December 2001, and in May 2005, the complex began receiving female inmates. The mission quickly changed, and male inmates started arriving on July 15, 2005. By September 2005, all female inmates had been transferred out.

LSCC sits on 100 acres and houses a total of 1050 medium security inmates, who are housed within two (2) living units, a 100-bed minimum security unit, and a 118-bed special management unit.

Additional construction of two living units began in November 2022, which will expand the inmate capacity by 832. The expansion is estimated to be completed by August 2025.

With the expansion, LSCC will be the second largest institution in Kentucky.

LSCC has numerous support buildings including academic and vocational schools, a medical unit, inmate canteen, correctional industries, a gym, dining facility, and maintenance area.

The Little Sandy Correctional Complex Mission statement is as follows: “To protect society by confining offenders in a controlled environment that is safe, humane, and secure. Also, to provide self-improvement opportunities that assist inmates in becoming productive citizens through education, correctional programs, and preparation for meaningful employment.”

D. Pre-Audit Meeting

The team met on Sunday, June 22, 2025, at the hotel in Morehead, Kentucky to discuss the information provided by the Association staff and the officials of Little

Sandy Correctional Complex.

The chairperson divided the standards into the following groups:

Shelia Oubre (Chairperson)

Standards # 5-ACI-1A-01 to #5-ACI-2G-03

Jessica Mallone (Member)

Standards #5-ACI-3A-01 to #5-ACI-5F-08

Michael Marutiak (Member)

Standards #5-ACI-6A-01 to #5-ACI-6E-05 to #5-ACI-7A-01 to #5-ACI-7B-15

E. The Audit Process

1. Transportation

The team was escorted to the facility by Gary Smith, Safety Coordinator.

2. Entrance Interview

The audit team proceeded to the conference room and met with Warden Ivan

Krow. The team expressed the appreciation of the Association for the opportunity to be involved with Little Sandy Correctional Complex’s reaccreditation process.

Ivan Krow, Warden, escorted the team to the Training Room where the formal entry meeting was held.

The following persons were in attendance:

Ivan Krow Warden

Joshua Montgomery Deputy Warden of Security

Heather Jarvis Deputy Warden of Programs

Lisa Brickey Unit Administrator II

Rhonda May Unit Administrator II

Chris Barker Unit Administrator II

Alvin Gillum Unit Administrator II

Derek Maggard Unit Administrator II

Brian Dickerson Major

Alicia Cantrell Offender Information Specialist Supervisor

Amber Barker Fiscal Manager

Gary Smith Fire and Safety Coordinator

Rita Harris Human Resource Specialist Institutional

Ricky Bear Maintenance Branch Manager

Jennifer Wright Institutional Training Coordinator

Joshua Jarvis Institutional Training Coordinator

Nicholas Moore Institutional Training Coordinator

Clarissa Bays Procedures and Development Specialist II

Carl Bossio Administrative Branch Manager Compliance

It was explained that the goal of the visiting team was to be as helpful and non-intrusive as possible during the audit. The chairperson emphasized the goals of accreditation toward the efficiency and effectiveness of correctional systems throughout the United States. The audit schedule was also discussed this time. The auditors were introduced to their assigned scribes, and instructions were given regarding the expectations.

The Audit Team then offered information about their respective professional backgrounds as well as experience with the expected practices and the accreditation process. The attendees then introduced themselves and their functions.

3. Facility Tour

The team toured the entire facility from 1036 hours to 1315 hours. The following people accompanied the team on the tour and responded to the team's questions concerning facility operations:

Ivan Krow Warden

Joshua Montgomery Deputy Warden of Security

Heather Jarvis Deputy Warden of Programs

Brian Dickerson Major

Gary Smith Fire and Safety Coordinator

Clarissa Bays Procedures and Development Specialist II

Carl Bossio Administrative Branch Manager Compliance

Division

ACA notifications were strategically 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:

LSCC is an adult male minimum/medium custody level complex, which was constructed in 2001. It is secured by two 12-foot chain link fences. The inside fence consists of five (5) rows of double coil razor wire, and the outer fence has three (3) rows of double coil wire.

All staff and visitors enter via the administration building. Both staff and visitors must produce a proper form of identification before being granted access to the facility. Only approved visitors are permitted entry into the facility. Before entering, both staff and visitors empty their pockets and belongings for items to be x-rayed.

The individual will then clear a walk-through metal detector. All visitors are given an ID badge to be kept on their person until they depart the facility.

The Armory is located offsite from the facility near their training department.

The facility carries a variety of weapon systems to suit the need of various incidents to include pistols, shotguns, Pepper Ball launchers, 40mm launchers, and tasers. Each weapons system is accompanied by a variety and abundance of munitions to utilize.

Detailed inventories are on hand of all items stored in the Armory. Service records for the weapons systems and monthly inventories were all up to date and stored accordingly. The Armory is well kept, clean, and highly organized. Little Sandy has an onsite range for training purposes. It is located just behind the training department.

The range was a sight to see, including a larger fenced off grass area with plenty of room to use. There were bays for the target stands and tabletops for easy loading and weapon manipulations.

The lock shop is a small office right inside the administration building. A keyboard is mounted to the wall, which was very well organized. The board was in order by key number and department. All key hooks had an identifier tag with the description and amount currently on hand. All inventories were current and stored accordingly.

The area was spotless; every cabinet was well organized in individual bins with everything labeled. Little Sandy uses a Key Watcher, electronic key boxes to issue and return keys needed for normal operations.

The main tool rooms are in maintenance, prison industries, vocational programs, medical/dental, outside grounds building, and food service. Tools are maintained on shadow boards and tool logs. All inventories were found to be accurate.

Little Sandy central control was impressive. The team was asked to provide identification, and approval was gained prior to entry. Various duties and responsibilities of the central control staff were observed. The post is slotted to have at least one supervisor and one officer on all three shifts. The primary job of central control is to monitor the camera system and keep accountability of all who enter or exit the facility. They have three large monitors in which to do so, offering plenty of visibility of all areas. There is an electronic control panel that operates the doors and gates for entry and exit. The camera system monitors these areas, and there is also a

COM. system that can be utilized to gain access. Central control is also responsible for issuing various equipment to include hand cuffs, OC spray, emergency keys, and the supplies utilized for emergency transport. All equipment is signed out ,and then signed back in upon return, on various logs organized by equipment type. The area was very well organized and clean overall, records were maintained, and the staff were in good spirits and more than helpful.

LSCC has one (1) tower. Entry to the tower was quite unique at Little Sandy. The review team accessed the side of central control and walked down a staircase which led to an underground tunnel. The tunnel, large in length, led us to the base of the tower. We climbed up a copious number of stairs and then arrived at our destination.

The officer greeted us and checked our identification. The tower contained a large monitor for viewing cameras of various posts and a panoramic view of the recreation field. Weapons systems were kept on hand in the event they were needed. All weapons and munitions were stored in a locked metal cabinet, to which only the

Tower officer and the supervisors have access. The exterior of the tower is surrounded by a balcony which the officer can access, walk around, and keep a constant visual on the surrounding areas. The tower is equipped with a bathroom for staff to utilize while posted there. Overall, the area was well maintained.

Special Management and Restrictive Housing:

The special management unit is a 118-bed unit consisting of 90 cells, four of which are dedicated observation cells. The unit is divided into seven wings. Wing

A, E, and F contain 14 beds each, wing B contains 16 beds, wings C and D contain

28 beds each, and observation consists of 4 beds.

Outdoor recreation consists of 18 individual bullpens. Program staff includes one unit administrator II, one unit administrator I, and one classification and treatment officer. Security staff consists of one unit sergeant, two floor officers, and one booth officer.

The unit is visited daily by each shift supervisor, mental health staff, and medical staff. Weekly visits are conducted by the warden, each deputy warden, duty officer, major, recreation, program, and academic staff, librarian, chaplain, DON, HSA, and the ARNP.

Meals are provided on the same schedule as the general population. Medication is administered twice daily.

Recreation, showers, and barber services are offered daily. Hygiene supplies, access to the telephone, and commissary is offered weekly. Fresh linen and clothing exchanges are offered three times per week. Mail and legal services are also available on a similar schedule to as the general population.

Environmental Conditions:

The facility's grounds are kept in good condition, with no signs of illegal dumping or improper disposal of materials. All staff members are trained in the proper handling and management of bio-hazardous materials and blood spills. Insect and vermin control services are provided monthly with additional treatments, as necessary. A well-structured maintenance plan is followed, ensuring regular checks and follow-up. There is a total of twelve (12) generators on the property.

Temperature checks of the water and living areas are taken regularly and meet required standards. The housing units are air-conditioned and have adequate working ventilation systems.

Sanitation:

The audit team was extremely impressed with the sanitation level throughout the facility. The facility has an outstanding and detailed housekeeping plan in place and uses it as a blueprint for maintaining its sanitation level. It was obvious to the auditors that the inmates took pride in keeping the facility clean. The required daily, weekly, and monthly sanitation inspections were well documented and met standard requirements.

The inmates are responsible for cleaning all the housing units and shared areas, and it was evident that the cleaning was continuous on all shifts. The cleanliness of the facility is the result of continuous cleaning 24/7 by the inmate population.

All the chemicals and cleaning supplies utilized for cleaning the facility were controlled, well documented and under lock and key.

The facility contracts outside vendors for solid waste removal, and services for vermin and insect control.

It was obvious to the auditors that the administration at the facility has an exceedingly high priority on sanitation. This was evident throughout the audit process as the auditors toured the facility and made visits/revisits to different areas and departments.

Fire Safety:

LSCC has a full-time Safety Coordinator, who is responsible for maintaining a safe and healthy workplace. This includes monthly fire drills, daily, weekly, monthly inspections, semi-annual and annual inspections of all Fire Protection systems.

LSCC has an Edwards EST 4 Fire Alarm System in place that consists of smoke detectors, heat detectors, sprinkler systems, and pull stations. The system is designed to identify exactly where the problem is so that staff can respond to the situation quickly and efficiently. All inspections were done in accordance with designated time frames in accordance with established policies.

All assigned vehicles are equipped with fire extinguishers and first aid kits. Both are inspected monthly, and the first aid kits have seals.

Eye wash stations are located throughout the facility and are being checked monthly.

There are 172 fire extinguishers (165 ABC, and 7 K) located throughout the facility, and they are all properly tagged and are inspected monthly. The type K extinguishers are located in the kitchen and staff kitchen/dining room. There are

16 fire hydrants on the property. And all buildings are equipped with sprinkler systems.

Fire and Life Safety equipment undergoes weekly inspections by Complex Duty

Officers, monthly inspections by the Safety Coordinator, and annual inspections by Johnson Controls. The kitchen exhaust hoods are cleaned biannually, by

Johnson Controls.

The facility has an assistance agreement with the following fire departments:

• Sandy Hook Fire and Rescue

• Rt 504 Fire Department

• Grayson Fire Department

• Olive Hill Fire Department

The State Fire Marshall conducts annual inspections and completes a report. Fire evacuation routes and exit signs are clearly posted throughout the facility.

Security staff undergo regular training on the use of fire equipment, and fire drills are conducted quarterly in all areas. During designated drills, emergency keys are used to verify proper operation and functionality. Inmates are evacuated to the secure yard during these drills.

Flammable materials and toxic chemicals are properly stored and inventoried.

Pre-mixed, diluted cleaning products are used for routine cleaning. A review of the facility's cleaning supply inventory, Safety Data Sheets, and safety equipment shows they are organized, properly labeled, and stored.

Food Service:

LSCC Food Service operates under contract with ARAMARK. The Food Service staff work as follows: 0330-1130 hours and 1000-1800 hours. There are sixty-five

(65) inmates assigned. Offender workers are medically screened and cleared prior to assignment.

The facility has two dining halls with a daily serving capacity of three hundred

(300) inmates.

The storage equipment includes freezers, walk-in coolers, and one dry storage area. Temperature logs are kept next to each designated area and are within the appropriate temperature range for each item. There are two (2) operational dishwashers, and rinse cycle temperatures were within established guidelines.

Inmates at LSCC are provided with three meals, two hot meals each day, with the third being either hot or cold. The meal service times are 0630 hours (breakfast), 1030 hours (lunch) and 1630 hours (dinner).

In addition to serving the three (3) required meals, inmates are afforded the opportunity to purchase other food items through the Retail Program, and 15% of all proceeds go to the Inmate Canteen Fund.

I Care-allows family and friends to order meals for the inmate up to four days a week. The inmate comes over at a scheduled time to pick up their order.

Fresh Favorite-is where an inmate can fill out an order form for pre-approved meals, once per week. They can spend up to $75 weekly. There is scheduled time for them to go to the kitchen to pick up.

Grill Card-is more of a restaurant style ordering. After the inmate is pre-approved via inmate accounts to have available funds, they are issued a grill card. They can go to the kitchen at a scheduled time, and order food that is prepared at that time.

The inmate may spend up to $75 weekly.

All tools and equipment were securely stored and properly inventoried. An inspection of chemical and cleaning supplies revealed that items were well-organized and accurately inventoried.

Restroom facilities for both offenders and staff were located within the kitchen area, hand-washing signs were posted, and the areas were neat and orderly.

An outside vendor performs hood suppression inspections every six months.

A certified dietitian reviews and approves the master menu system.

The cost of each offender meal per day is $.97

Both general and medical diets follow a four-week rotating menu cycle. Medical and religious diets are provided following review and administrative approval. At the time of inspection, the facility had the following special diets: Renal, Mechanical Soft, Wasting Syndrome, Common Fare Kosher, and Common Fare

Vegan.

On Thursday, June 26, 2025, the team consumed the lunch meal which consisted of the following: peanut butter and jelly sandwich, salad, potatoes, cake, apple sauce, bread, and salad dressing. The meal was palatable and met the nutritional requirements.

LSCC Inmate Canteen is operated by Union Supply. There are over 600 products that are available for purchase. The canteen is operational Monday-Thursday from 0730-1800 hours. Inmates can place commissary food orders on their assigned tablets or through the inmate phone service once per week. Inmates can also place a vendor order (up to three per quarter) through Union Supply Direct and additional food orders. They are allowed to spend $125 up to four times a year, or they can have family members to order from the website, mail, phone, or fax.

Special Management inmates may place a canteen order weekly.

Medical Care:

Resources and Locations:

The LSCC medical and mental health services are provided under contract with

Wellpath. The current contract ends in 2028. Services such as radiology, optometry, and physical therapy are provided onsite by Wellpath staff. Dental services are provided by Mid-America under contract with the KDOC. Other services are provided through outside contracts.

The LSCC health care services are in a portion of a multipurpose building shared with Food Service and the Laundry and about halfway between the main entrance and the end of the open yards. The area itself was well lit with ample, even enormous workspace for the staff and for efficient operation. A member of the audit team visited and inspected the location several times. Dental services are located adjacent to the medical area as are the mental health offices.

The design of the medical hallways and doors can accommodate inmates with disabilities 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 health care area itself has two examination rooms for providers, two other examination rooms for mental health calls and counseling, another examination room used by nurses for sick call and by the physician when onsite, and yet another examination room used for telehealth and mental health, a ER and triage room, an optometry room, a lab room, offices for the Health Services Administrator, Director of Nursing, and Administrative Assistant, a conference room (currently used by mental health and records staff), a break room for staff, storage rooms for oxygen tanks, wheelchairs and adoptive devices and general items, two staff restrooms and an inmate restroom, a biohazard waste storage room, a linen closet, several janitorial closets, two offices for nurse practitioners, an x-ray room, four single-cell observation rooms, a medication room a Nurses’ Station, a medical supply storage room, a physical therapy room, a temporary holding room, a dental suite with an office and a storage area, and an Officer’s “cab” area. There is no negative pressure room. Health services have a “golf cart” type vehicle for quick access to areas of the institution.

Additionally, there is an examination room in the Special Management Unit and a mental health room in the same building. The Minimum-Security Unit (MSU) has a medical room with examination table and pill cart.

Inmates are sent to the medical area individually or in small groups. The waiting area is a locked room with benches for seating for about 25 inmates. The waiting area has health-related posters. A restroom and basin are nearby with staff assistance to access them. The waiting area was clean and sanitized. An Officers’

Station is positioned immediately across the hallway window of the waiting room for direct observation.

A standard of cleanliness, hygiene and orderliness was observed. Staff in all areas expressed complete satisfaction with the working space and layout. All noted areas appeared well organized when viewed by the audit team.

Staffing for Health Care:

Medical:

Physician and Medical Director –

It was noted that the LSCC’s Medical Director is a regional staff person who is rarely onsite but who sees complex cases by telehealth when referred by another provider.

Advance Practice Registered Nurses (3) – (all full-time)

Health Services Administrator

Assistant Health Services Administrator

Director of Nursing – (currently a vacant position)

Registered Nurse for Medication Assisted Therapy

Registered Nurses (5)

Licensed Practical Nurses (7)

Certified Medical Technicians (4)

Medical Records Clerk

Administrative Assistants (3)

Physical Therapist – (five days a week, split between two therapists)

Optometrist – (contracted, one day a week)

Dental:

Dentist – (part-time, one day per week, vendor, open position for a two day per week dentist

Dental Assistant – (part-time, three days per week)

Mental Health:

Psychiatrist – (State MH Director, part-time at the LSCC by telehealth)

Mental Health Professionals (4)

Psychiatric Nurse Practitioner (2) – (one not onsite, by telehealth, temporary until a position is filled)

It was noted that LSCC has hired three new mental health personnel, an LCSW, and an LPA, all with start dates the month following the audit.

Medical Records:

The medical records are kept in electronic format through the eOMIS system, with a list of authorized people/positions to access the records and login codes.

Medications are managed and recorded electronically. The records are accessible by other authorized Wellpath and KDOC 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 15 distinct sections with electronic tabs separating the respective sections and documentation or notations in chronological order.

Inactive paper records for deceased and discharged inmates are retained according to an established schedule 20 years afterwards. The electronic records are permanent and accessible to each medical department upon an inmate’s transfer.

Infirmary, Medical Housing, and Medical Observation:

The LSCC does not have an infirmary. Inmates in need of infirmary care are sent to a KDOC- facility, usually the Kentucky State Reformatory, or to Ashland

Hospital Corporation (d/b/a Kings Daughter’s Medical Center).

The four observation cells in the medical area have video coverage inside of the cell. The video feeds to a large screen in the Nurses’ Station and to the Officers’ desk. An auditor observed the quality of video coverage and how it was monitored by staff. The cells are each equipped with a toilet, wash basin, and shower (ratio

1:1). Observation rounds are regularly conducted by medical and security staff.

Services and Care:

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

Clinical services are accordingly five days a week, and sick calls are seven days.

The credentialing log and job descriptions for health care staff were current and documented in the ACA files.

The LSCC receives inmates for most levels of medical care, except those in need of total nursing care. Walkers and wheelchairs are used by some inmates on a short-term or lengthy basis. The facility is equipped to house inmates with hearing impairments, and the general population units have wings with a Vitek hearing system (green lighted alerts).

Provided services at the LSCC include orientation, in-take screening, emergency care, sick call, pill call, dental, 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 include oncology, radiology, and urology, among others.

Upon admission to the LSCC, all system inmates (from KDOC assessment facilities) are initially screened by a nurse (normally an LPN) for medical, mental health and dental issues. The initial screening includes an orientation (“Inmate

Medical Orientation”), “KOP” medications, “sick call” procedures, grievance procedures, PREA information, a handbook, and other medical educational guides.

Symptoms of tuberculosis and MRSA are screened as part of the intake. A checklist form is used to ensure all points are covered with the inmate, and the inmate signs for his acknowledgment of the same.

Electronic forms are used for intra-system transfers (“Condensed Health Services

Encounter”). Within fourteen (14) days of the intake, inmates are seen by practitioners for a more comprehensive evaluation and history – the health care physical assessment). Documentation showed many health assessments were conducted near the same day as the intake.

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.

An individual treatment plan (ITP) is written for all inmates in a chronic care category within 30 days of diagnosis. 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 90 days.

It was noted by the auditor that a default time frame for review of chronic care cases could not be found in policy. The 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 conditions 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. Statical reports showed a wide range of monthly chronic case management services, from a couple of dozen to about 200.

Chronic care inmates receive annual physical examinations.

Written plans (or policies) are in place for the management of Hepatitis A, B, and

C, HIV, MRSA management, influenza, body lice, exposure control, and all reportable diseases. Policies and manuals address prevention, education, follow-up, and report requirements for communicable diseases. The LSCC follows the

Federal Bureau of Prisons’ Guidelines for many communicable disease protocols.

HIV testing is offered to inmates during the system intake process and later during medical appraisals and HIV educational material is included in the orientation materials. HIV testing can be declined by the inmates except for testing at the end of one’s sentence and prior to release. An Infection Control Manual was present.

Sick-call requests, medication refills, and clinical and specialty services are routinely initiated through a simplified system of request forms. Sick call is conducted every morning starting at 6:45 a.m. For general population inmates, an inmate needs only to report to his housing staff that he wishes to attend the daily sick-call and then go to the medical area where he can deliver his written “sick call request” to a nurse. An auditor reviewed multiple and random copies of the related documentation showing the dates of requests and the date and nurse who addresses them. With few exceptions of a day’s delay, the records showed sick calls were addressed on the day of the request (corroborated by verbal reports from interviewed inmates).

For the Special Management Unit, twice daily rounds are made by medical staff so inmates can submit written requests by placing them in the cell door. If an inmate in Special Management is unable to complete his own sick call request due to impairment or disability, staff will assist him, or he can speak with a nurse during the time of rounds. Sick-call referrals for an inmate may also be generated by any staff member. To give a perspective, health care at the LSCC receives 300-400 sick call requests a month, including those for dental or mental health services.

Periodic health examinations are scheduled every year for inmates over 50 years of age, every three years for those 50 or under, and every year for chronic care cases.

Diagnostic tests are included in the periodic exams. All chronic care inmates receive examinations every year. Inmates on psychotropic medications are evaluated at least every 90 days.

Tuberculosis testing of inmates is done upon intake to the system (as is voluntary

HIV testing) and annually thereafter. KDOC policy provides for testing within ten days of an inmate’s admission to the system. 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, prior to job assignment, and periodically thereafter.

A clear 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. Outside hospitals are the Saint Claire

Regional Medical Center in Morehead or the Kings Daughter’s Medical Center in

Ashland. For emergencies, the Elliot County EMS is dispatched (a letter of agreement exists between the LSCC and the EMS).

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, walkers, crutches, hearing aids, and eyeglasses for inmates, as ordered by a provider. An auditor viewed some of the items and reviewed past provider orders for eyeglasses and hearing aids. The items appeared organized and sanitized. An inmate can be transferred to a disability placement program at another facility. A room in the medical area is used for physical therapy. A Wellpath physical therapist is onsite two days a week.

The LSCC operates a six-month therapeutic Substance Abuse Program (SAP) in a separate residential housing area. Access to the program is accomplished by identifying those inmates in need, followed by an application and acceptance.

Inmates also receive substance abuse information through nursing staff, social services, and upon parole or discharge. At any given time, about 10% of the facility’s inmate population is involved in the therapeutic program.

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. Narcan is maintained in the medication room, in the emergency jump bags, in security’s response bags, and in proximity to the Mailroom. An auditor observed and checked Narcan placed inside of the Mailroom, which to the facility’s credit, may have been the adoption of a suggestion made during the first day of the audit.

Laboratory specimens are taken at the LSCC (a “draw lab” only) so the specimens can be processed by Lab Corp., who collects the specimens. Providers and medical staff at the LSCC then receive the results for review. STAT labs can be provided by the local hospital. Mobile X-Ray is contracted for radiology services.

The co-pay charge for routine sick-call appointments and non-formulary medications and similar services is $3.00, excluding mental health services, staff-initiated requests, follow-up appointments, and other usual exemptions. Inmates are informed of the co-pay requirement at many and various stages of intake, verbally and in writing.

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. The examples viewed showed response times of 2-3 minutes. There was documentation of medical staff training in the facility’s emergency responses.

Five AEDs are in place in the facility: in the medical area, in two housing units, and in Special Management and minimum security. 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. The facility listed first-aid kits, but all of them are for vehicles, industries, maintenance, and the armory. Medical staff restock the kits when custody staff bring them after use and otherwise check them monthly. The routine practice, however, is for staff to send an inmate with any type of injury to the medical area. Self-harm prevention garments (blanket and smock) are maintained and were observed in use by an auditor.

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, and a daily list is maintained where the diets are prepared.

At the time of the audit, there were 56 inmates on therapeutic diets. A Therapeutic

Diet Manual (dated 2018) was present in the Food Service area.

The LSCC 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, or residents were used in health care during the audit period.

Policies are in place should inmate assistants, students, et. al, be used. Inmates are used for constant observation of suicide potential inmates, and a policy and training program is in place for such work. The training is conducted by mental health or medical staff.

A written policy permits inmate participation after approval in medical or pharmaceutical research.

Inmate interviews gave the impression that inmates do not view Health Care as part of the LSCC security operation, an impression that leads to better and more honest communications between the inmates and Health Care staff. Overall, when inmates were asked, they had no articulated complaints to express about Health Care services. Inmates expressed general satisfaction with the timeliness of medical callouts and responses. An auditor requested a “snapshot” during an afternoon of those waiting for sick call appointments and those waiting for outside consults and assessed the numbers as normal for a facility the size and nature of the LSCC (in a rural area).

The audit team was well satisfied with the documentation and interviews demonstrating a continuity of care from intake to discharge or release. Senior health care staff expressed their desire to always work in conjunction with security and programming staff.

Medications and Pharmacy:

All medications are ordered through Diamond Pharmacy by means of an electronic system and normally delivered the following day. There is a back-up, local pharmacy, Drug Mart. The administration of medications is electronically recorded on the MAR system.

Narcotics are kept in the pill carts in a separate and locked box. They are inventoried at the beginning and end of each shift by two nurses, one from the incoming shift and one from the outgoing shift, in a logbook only for controlled substances. A “balance count’ system is used. The HSA conducts random checks of narcotic inventories and other medication supplies. 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. Refrigerated medications and vaccines were similarly inventoried and maintained at a correct temperature (40 degrees).

Most medications, excluding some controlled substances, are received in blister packs, and administered at one of the two pharmacy pill windows twice daily (8:00

am. and 8:00 pm. for general population and 5:00 am. and 5:00 pm. for Special

Management). There are additional times for diabetic lines. The two general population pill windows are divided alphabetically according to the last names.

For inmates in Special Management, medication administration is done by a nurse at the cell using one of the medication carts. KOP (keep on person) blister packs are allowed. A procedure is in place for confirming an inmate’s identity and for a post-administration “mouth cavity check.” The total number of prescriptions filled monthly is 2,000-3,000. Certified Medical Technicians normally work in the medication room and administer the medications during pill calls. The medication room has video surveillance.

An audit team member viewed the current formulary (January 2025 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 were noted. Decontamination protocols are used daily. A process is in place for obtaining non-formulary medications if needed.

Selected over-the-counter medications can be bought by inmates in the commissary from a list approved by the Medical Director.

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 another medical supervisor. A quarterly audit of the medication room and procedures is done by a pharmacist from Diamond in addition to Wellpath audits. An auditor requested and received copies of Diamond audits from 2024 and 2025. Those audit reports did not document any deficiencies or areas of concern. No medication errors were noted in the Outcome Measures.

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. Inventories were randomly checked. An audit team member found the inventories to be accurate and consistent.

The 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 dental staff are present) with a similar “running balance” system used for controlled substances counts. 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 at least 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 groups of ten (10), and then retaped to show a count was done). Medical instruments are kept in a small room adjacent to the medication area.

Examples of all sharps and instruments were maintained in durable plastic covers in a binder book to assist nursing staff and, in the event of an unaccounted item, an example can be shown to security staff. Security staff do reconciliation counts of sharps and instruments on a weekly basis.

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, ventilated room with a sprinkler system and used exclusively for biohazard waste.

An autoclave (Tuttnauer model) 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. Checks are performed twice weekly.

Quality Improvement Program:

There is a Quality Improvement Program (“CQI” meetings) as well as regularly reviewed health care specific goals and objectives in place at the LSCC, all documented in the audit files. The Committee meets quarterly. Custody and administrative staff (Warden, Deputy of Security, and others) are committee members, as required, as well as medical and mental health staff and housing unit administrators.

Components of the program (documented in meeting minutes) are the utilization of management reviews, epidemics, risk management, environmental inspection reports, infection control, grievances, disaster and “man down drills,” mortality reviews, assessments and emergency services for inmates with mental health concerns, and staff development. The meetings are often combined with Infection

Control meetings.

Quarterly and annual reports are issued. The Medical Administration Committee

(MAC) also focuses on performance improvement (the Warden, and HSA are members, among others). 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 monthly activity report to

Wellpath. A monthly Special Management Unit Meeting occurs with the Warden, Deputy Warden, medical and mental health managers, and housing counselors, to review the status and recommendations for all inmates in SMU.

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.

Health Care outcomes are monitored on a regular basis, as shown in the meeting minutes.

The LSCC develops and issues an Annual Planning Document (as all KDOC facilities do) that includes a section on health care services with goals and objectives.

A Quarterly Safety Meeting occurs, by policy, for the prevention of injuries by inmates and staff.

No staff member interviewed in the health care areas expressed any concern or experience of having health care decisions overridden or interfered with by non-medical staff; on the contrary, most staff members described a comfortable and effective working relationship with the non-health care departments.

Sufficient documentation was present to show that external peer reviews are being done for the physician, psychologist, and dentist as required and when due. Some confirmation memorandums were provided along with blank copies showing the criteria to be used for all three professional categories. The current dentist, who started at the LSCC just this month, is not yet due for review. The psychologist was externally reviewed in 2023 and 2024 by the Regional Mental Health Director or by an LPA. As already noted, the physician’s position has been covered by the offsite Regional Medical Director. An auditor concluded that the external review process was satisfactory, meaningful, and substantive based on the criteria being used and the number of files examined for those reviewed, though the newness of many staff did not require reviews yet.

Dental Care:

The dental area is adjacent to the medical area. As noted earlier, dental care is provided by contract or subcontract by a part-time dentist and a part-time dental assistant. Preventive and restorative services, denture and partial work, cleanings, extractions, and x-rays are provided. Oral surgeries that cannot be done at the

LSCC are referred to an outside source.

The dental area has two (2) working chairs. Dental classifications range from Class

I (no care needed) to Class 2 (routine care), to Class 3 (urgent), to Class 4

(emergency, high priority).

On average, there are about 65 inmates seen each month by the dentist and an additional 40 by the assistant. The Health Care Outcome Measures report 300-1200 completed dental plans in the years under audit.

Dental care includes screening at intake by nursing staff and a later comprehensive assessment by the dentist when needed and/or requested. Dental examinations and treatment include a uniform dental record, medical history, vital signs if required, periodontal screening, and a priority of treatment scale.

Nursing staff triage any after-hours emergencies and contact the on-call dentist if the nursing protocols are insufficient for the situation. A protocol and contact information are in place for dental emergencies.

Inmates are provided with educational information on proper oral hygiene and care, as demonstrated by literature and graphics on brushing and flossing and other written information given to inmates upon arrival.

Mental Health and Suicide Prevention:

As noted earlier in this report, mental health staffing consists of four mental health professionals, one of whom is a psychologist, two Psychiatric Nurse Practitioners, one onsite and one available by telehealth, and the availability of a psychiatrist by telehealth. Three additional mental health professionals are to begin work at the

LSCC soon. All but one of the mental health staff began work at the LSCC during

Year #3 of the audit period, mostly in December 2024, so their requirement for annual training (12 hours) is not complete, nor does it need to be. Training for the psychologist was documented for Year #1 and #2 of the audit periods but not yet completed for Year #3. (In terms of training requirements, the facility follows calendar years, not necessarily ACA audit years.)

Most of the initial inmate contact with mental health staff occur as the result of a referral, usually during the intake screening process by an LPN. Inmates may generate a request to mental health of course by the sick-call system or by verbal request. The process can also be generated by a referral from any staff member at any time.

Those inmates referred, whether at intake or any time later by any staff member, for mental health concerns receive an assessment by a mental health professional within 14 days, although documentation demonstrated the assessment usually occurred earlier. Irrespective of any referral, policy provides that all intakes to a facility are to receive a mental health appraisal within 14 days.

Outpatient services include screening and/or assessment, crisis management, Individual counseling, group therapy, a psychiatric evaluation if warranted, and medication management, as well as discharge and release planning. The Outcomes report 11%-34%, year-to-year, of inmates at the LSCC had an active individualized treatment plan for a diagnosed mental disorder excluding a sole diagnosis for substance abuse. For the most recent calendar year (2024), the mental health caseloads were 370-400 each month.

When a mental health evaluation or related treatment beyond the present capabilities of the…